Saudi Journal of Ophthalmology (2013) 27, 267—269
Original article
Methods to reduce prescription errors in ophthalmic medication Saqib A.K. Utman, MBBS, MRCOphth, FRCS a,⇑; Peter L. Atkinson, MBChB, FRCOphth, FRCS b; Hanna M. Baig, MBBS c
Abstract Purpose: The purpose of this audit was to determine the most common medication related prescription errors in ophthalmic practice, to determine avoidable prescription errors and evaluate the effect of preventative methods against these errors. Methods: The first audit was conducted prospectively over a four week period in Oct 2009 and a re-audit after 6 months on May 2010, to determine the effects of preventative measures suggested in the first audit. Results: There were 4.7% (29/623) prescription errors during the initial four week audit period. A method of check and counter check of prescriptions was implemented and re-audit showed a reduction in incidence of errors to 0.77% (5/651) errors. Conclusions: The majority of prescribing errors occurred at the stage of writing the prescription and our findings suggest that the intervention of check and counter check can reduce the rate of error significantly. Keywords: Prescription errors, Ophthalmic medication, Methods to avoid Ó 2013 Production and hosting by Elsevier B.V. on behalf of Saudi Ophthalmological Society, King Saud University. http://dx.doi.org/10.1016/j.sjopt.2013.09.003
Introduction
Methodology
Errors in prescribing medications are common. Twenty percent of all medical negligence treatment claims arise from incorrect use of prescription drugs.1 Prescribing errors are not only costly to individuals but also have a financial impact on government Health Services. These errors can occur at several stages, including prescribing, transcription, dispensing and administration, effects varying in severity from minimal, and thereby unrecognized to be fatal.2,3 A previous study estimated the accuracy that 6.5% of the prescribing errors were clinically significant.4 A study by Mandal et al.5 reported 7% of all the prescription related errors were due to incorrect format or illegible. In this audit we determined the most frequently occurring writing errors when prescribing ophthalmic medications and ascertained preventable prescribing errors and recommend measures to avoid these errors.
This prospective study, evaluated the incidence of errors in written prescriptions at a single Teaching Hospital Eye unit. A correct script for medication should include the exact details of the patient, allergy status of the patient, correct medicine with correct dosage, site and frequency, a legible signature and name of the prescribing physician to prevent any adverse clinical events. The first audit was conducted prospectively over a four week period in Oct 2009 and a re-audit after six months in May 2010 after implementation of recommendations of the first audit. The prescriptions were evaluated during the working hours of the pharmacy (9 am to 5 pm) and evening and weekend scripts were excluded. Data were collected on the type of errors, person responsible for the errors and measures taken to rectify the error were recorded on a data collection sheet. A pharmacist was instructed to notify the clinicians about the errors and
Received 2 November 2011; received in revised form 18 March 2013; accepted 15 September 2013; available online 25 September 2013. a b c
Moorfields Eye Hospital, London, UK Bradford Royal Infirmary, Bradford, UK University Hospitals Coventry and Warwickshire, Coventry, UK
⇑ Corresponding author. Address: Moorfields Eye Hospital London, 162 City Road, London EC1V 2PD, UK. Tel.: +44 7985426944. e-mail address:
[email protected] (S.A.K. Utman). Peer review under responsibility of Saudi Ophthalmological Society, King Saud University
Production and hosting by Elsevier
Access this article online: www.saudiophthaljournal.com www.sciencedirect.com
268
S.A.K. Utman et al.
to record the errors on the data collection sheet and instruct clinicians to fill out a data collection for audit. The study was approved by the hospital audit committee.
Results There were 623 total prescriptions issued during the first audit period. Of these, 29 (4.7%) prescriptions had script writing errors; some with more than one error. The majority (22 of 29) of script writing errors were reported by the pharmacists and 7 by the two ophthalmologists during clinical consultations. Junior doctors were responsible for 21 errors (18 by Specialist Registrars (Senior residents) and 3 by Senior House Officers (Junior residents)). Consultants were responsible for 5 errors. Two patients were unable to understand how to use the medicine correctly due to unclear instructions. One patient was prescribed the wrong medicine as a repeat prescription by the general practitioner. The most frequent error was the lack of allergy status for 7 prescriptions (Table 1). The majority of the script errors were by ophthalmologists (82.75%). However the accuracy of written scripts was 99.53%. Almost all errors were preventable and rectified appropriately. After the first audit we recommended that prescription scripts should be checked by the prescribing physician and re-checked by the nurse assistant in the clinic. Additionally we recommended that patients should be advised to bring all topical medications to determine whether they understand the exact dosage and frequency of each medication. After implementation of changes a re-audit was performed for one month, 6 months after the first audit. Results of the re-audit are presented in Table 1. During the period of the re-audit, a total of 651 prescriptions were written. Of these, only 5 (0.77%) errors were recorded. Junior physicians were responsible for all errors (4 by Specialist registrars and 1 by Senior House Officer). One error was recorded by an ophthalmologist and 4 by the pharmacists during the 4 week re-audit period. All errors were preventable and no patient was harmed.
Discussion Not surprisingly many patients requiring ocular medications have poor sight, resulting in numerous mishaps with topical ocular medications.5 There is systemic absorption of
high dosage of topical medications with incorrect administration. In this study we found that neglecting to indicate allergies to medications was the most common error prior to re-audit. Anaphylactic reactions to penicillin alone cause 400 deaths per year in the United States.6 Hence the allergy status of the patient is fundamental to avoid serious and potential lethal complications. Flynn et al.4 estimated the accuracy of dispensing prescriptions was 98.3% and 6.5% of the errors were clinically significant. We found that there were 4.7% prescription errors during the first audit and 0.77% errors during the re-audit. Mandal et al.5 reported that 144/1952 of ophthalmic prescriptions had incorrect formats or were not legible which constituted 7% of the total errors. However in our first audit, only 1/29 prescriptions were illegible and constituted 3.5% of the total errors. Hospitals routinely have senior, intermediate and junior physicians working is the same wards. We found that junior physicians were more likely to commit more errors compared to senior staff. A possible explanation for this observation could be that there are more junior physicians working in our teaching hospital and are prone to prescribe more medications than the senior physicians. Based on these outcomes we strongly advocate more training of junior physicians to avoid these errors and to understand the potential hazards due to prescription errors. It is fundamental that patients attending an outpatient ophthalmic clinic bring all their topical medications in order to determine how they instill their drops. This is of particular importance for postoperative patients.7 This is also an opportunity to review the proper instillation and frequency of topical medications. Computer-based prescribing systems may minimize the risk of errors due to illegible prescriptions. However there is a considerable financial investment and training involved which may be prohibitive for some institutions.7 Knowledge of where and when errors are most likely to occur is generally the first step in prevention of prescription errors. Our first audit showed that the majority of errors occurred when the prescription was being written and our re-audit findings suggest that an intervention of check and double check prior to issuing the prescription to the patient, reduced the prescribing errors significantly.
Conflict of interest Table 1. Ophthalmic prescription errors during the first audit and a second audit after implementing preventative measures. Type of errors
First audit
Second audit
Wrong drug/strength Illegible No signature No prescription issued Patient unable to understand instructions Wrong re-prescription by general practitioner Wrong/no site written No frequency of usage No instructions on the forms No drug strength Allergy status No patient details on the prescription
3 1 1 1 2 1
1 0 1 0 0 0
3 5 4 1 7 0
1 0 0 0 1 1
The authors declared that there is no conflict of interest.
Acknowledgements The authors acknowledge the help of Staff of Ophthalmology Department and Pharmacy of Bradford Royal Infirmary for their assistance during the audits.
References 1. Donaldson L. An organisation with a memory. Clin. Med. 2002;2:452–7. 2. Chua SS, Wong IC, Edmondson H, Allen C, Chow J, Peacham J, et al. A feasibility study for recording of dispensing errors and near misses in four UK primary care pharmacies. Drug Saf. 2003;26:803–13.
Methods to reduce prescription errors in ophthalmic medication 3. Shah P, O’Driscoll AM, Fouladi MK, Pereira AM, McDonnell PJ. Inadvertent instillation of Minims eye drops in an ophthalmic casualty department. Acta Ophthalmol. Scand. 1995;73:89. 4. Flynn EA, Barker KN, Carnahan BJ. National observational study of prescription dispensing accuracy and safety in 50 pharmacies. J. Am. Pharm. Assoc. 2003;43:191–200. 5. Mandal K, Fraser SG. The incidence of prescribing errors in an eye hospital. BMC Ophthalmology 2005;5:4.
269 6. ‘‘AAAAI – anaphylaxis, cause of anaphylaxis, prevention, allergist, anaphylaxis statistics’’. Archived from the original on 2010–11-16. Retrieved 2007–12-03. 7. Mein Eleanor, Sii Freda, Shah Peter. An ocular medication dispensing error. Br. J. Clin. Pharmacol. 2006;62(6):715–6.
