Unregistered User If this is not your name, click here.
		Contact Us | Order Now | Journals | Bookstore | Register a colleague
	Select a ChannelAcneAIDS and HIVAllergy OtherAlzheimer'sAnaesthesiology OtherAngina Pectoris/MIAnxietyArthritis OtherAsthmaBack PainBacterial InfectionsBladder CancerBone Marrow TransplantationBreast CancerCardiology OtherCataractCell TransplantationCervical CancerCholesterol/Lipid disordersCirrhosisClinical PharmacologyColorectal CancerCongestive Heart FailureContact DermatitisContraceptionCOPDCystic FibrosisDental and Oral DisordersDepressionDermatology OtherDiabetesDialysisEating DisordersElbowEmergency MedicineEndocrinology OtherEpilepsyErectile DysfunctionFibromyalgiaGastro OtherGeneticsGenitourinary OtherGeriatricsGERD/GastritisGlaucomaH. Pylori/UlcerHaematology OtherHair LossHeadachesHepa/Biliary OtherHepatitisHipHRTHypertensionIBDImmunologyInfectious OtherInfertilityIntensive CareIrritable Bowel SyndromeKneeLeukemiasLiver CancerLung CancerLupusLymphomasMelanomaMenopauseMultiple Sclerosis Nephrology OtherNeurologic OtherNutritional / Metabolic OtherOb/Gyn OtherObesityOncology OtherOphth. OtherOphthalmic SurgeryOrgan TransplantationOrthopaedics OtherOsteoarthritisOsteoporosisOtitisOtorhino. OtherOvarian CancerPaediatricsPainPancreatic CancerParkinson'sPregnancyProstate CancerPsychiatry OtherPulmonary OtherRadiologyRenal CancerRenal FailureRespiratory InfectionsRheumatoid arthritisRheumatology OtherRhinitisSchizophreniaShoulderSleep ApnoeaSleep DisordersSpineStrokeSTDsSurgeryThyroid DisordersTransfusionTransplant Surgery OtherTraumaUrinary IncontinenceUrinary tract infectionsVaccinologyVascular DisordersViral Infections

SEARCH   News Bookstore Medline The Web Meetings & Congresses Complete Doctor's Guide    EXPLORE :    All News   All Webcasts   All Cases   All Meetings & Congresses   All Medical Resources New drugs / indications English Dictionary Medical Dictionary Thesaurus Warning | Privacy | Awards  Favourite Journals  Click here to choose your favourite journals  Favourite Sites  Click here to choose your favourite sites  Languages  Select languageEnglishFrançais

ASHP: Human Error Causes of Medication Errors Discovered By Maury M. Breecher, PhD., MPH SAN DIEGO, CA -- June 4, 2003 -- Doctor, do you use your zeros correctly when writing prescriptions? Most medical doctors don't, according to an analysis of 165 medication errors at a 535-bed tertiary care teaching hospital. Other common human errors involving hospital medications are pharmacists' failure to clarify ambiguous drug orders, physicians who have illegible handwriting or those who use unapproved abbreviations, and nurses' failure to use the "Five Rights" protocol for ensuring proper medication dispensing. The findings were presented here at the American Society of Health-System Pharmacists (ASHP) annual summer meeting. The study used a unique research methodology called "Common Cause Analysis," a tool previously used in high-risk industries such as nuclear power plants and aviation. Selected healthcare professionals at the teaching hospital were taught to identify one or more of 28 "common cause" inappropriate actions involved in the 165 reported medication incidents. The purpose of the study was to identify underlying common human errors and understand the safety issues involved so that corrections could be made, explained one of the study authors, Katherine R. Jones, PharmD, a medication safety and investigational drug pharmacist at Memorial Health University Medical Center, in Savannah, Georgia. "When we analyse the root causes of all the medication errors we find the most human errors occur when people take shortcuts of various types," said Dr. Jones. "There were three areas where shortcutting most often resulted in errors -- physicians' illegible handwriting, nurses not performing the "Five Rights," and pharmacists not clarifying the doctor's ambiguous or illegible orders" Nursing Errors "Every nurse, prior to drug administration, is supposed to go through a mental checklist which they have been taught as the "Five Rights " -- right drug, right patient, right route, right dose, and right time," said Dr. Jones. "Nevertheless, our analysis revealed that one of the common causes of medication errors is that nurses forget to go through that checklist." Nurses forget to go through the "Five Rights" most often during busy periods such as 9 a.m. medication delivery, she continued. Physician Handwriting and Use of Abbreviations Two of the common handwriting errors made by physicians, said Dr. Jones, is forgetting to write out the word "unit" and having a "trailing zero". A "trailing zero" is when a physician writes a unit measurement ending with a decimal point followed by zero. For instance, if a prescription is written for 5.0 units, but the decimal point is faded out or not seen, "It could cause a tenfold error," Dr. Jones pointed out. "It's very difficult for physicians to get that right because they were trained in their math and science backgrounds to use the point zero formation. However, when it comes to patient safety, it is a very bad thing." "On the flip side, though, you need to have a preceding zero before a decimal because if it is not there, oftentimes the decimal point is not seen and, again, that can cause a tenfold error," she continued. (Example 0.5 units. Without the zero, the decimal point might not be seen, and instead of getting a half unit dose the patient would get 5 units). Another common physician error when writing prescriptions is failure to include the indication or disease for which the prescription is written. "There are so many sound-alike, look-alike drug names out there that writing out why the drug is being prescribed provides an added measure of patient protection," said Dr. Jones. Pharmacist Clarification Errors Pharmacists who fail to clarify an uncertainty about a prescription with the prescribing doctor often give the reason that physicians take too long to return such phone calls, said Dr. Jones. However, part of the study involved a medication safety quiz in which 160 pharmacists were asked how long it actually took medical doctors to return their calls. "Most physicians call back within 5 minutes, according to the pharmacists in our study," she said. "The average was 61 minutes, but the mean was only 5 minutes, so that part of our analysis indicates that only a few of the medical doctors were fueling the misconception that most took too long to respond." E-mail this page to a friend or colleague! To print, use this version