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Corrective Actions to Reduce Medication Errors

Unfortunately we all make mistakes, even physicians. So when it comes down to the care of a patient it is important to take all appropriate measures to prevent medication errors. In a 2009 article by Vilo and Minuz, they reported a wide range of prescription errors that can vary from 2 to 514 per 1000 prescriptions written and from 4.2 to 82% of patients for charts reviewed.

However, we find that oftentimes, simple steps can be implemented to reduce or perhaps eliminate many such errors. This can have a significant impact on the care being provided to the patient. We know the importance of performing a root cause analysis to assess why an error occurs. But it is also important to implement corrective measures in a timely fashion to reduce the rate of the error or eliminate the error completely.

One method proposed by Howell and Jones to reduce prescription writing errors in a family practice setting is to simply add the patient’s diagnosis to the prescription. When screening for duplicate prescriptions, they found it easier to evaluate the prescription writing process as well as the decision making process that led to writing the patient’s particular prescription initially. An excerpt describes their approach.

The prescription-writing errors of Shaughnessy and Nickel were revised to include prescription-writing markers. These markers were defined as either an indication of use or a duration of therapy that differed from current medical literature or manufacturers’ recommendations. Duplicate prescriptions of first-year family practice residents were reviewed for prescription-writing errors and markers before and after an in-service training regarding prescription writing.

Following the in-service training, the number of prescriptions containing the patient’s diagnosis increased significantly (20% to 61%). Nineteen percent of all prescriptions contained prescription-writing errors. Eight percent of the prescriptions with the patient’s diagnosis contained prescription-writing markers.”

Their work suggests that on occasion, simple steps such as including the diagnosis on the prescription can reduce prescription-writing errors and have a significant impact on the care being provided to the patient.

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