Alternative to doctor’s poor penmanship

In India, though a vast number of drugs are available, records of medication errors are never maintained, say Arlene Avileli, Pooja Borkar, Shailaja Mallya, Raj Vaidya in Part I

ERRORS involving prescription medications kill around 7,000 Americans a year and the financial costs of drug-related morbidity and mortality may run to nearly $77 billion a year. In India, though a vast number of drugs are available, records of whatsoever

medication errors occurring are never maintained.

The statistics for Indians, in fact, could be even more staggering.

The National Coordinating Council for Medication Error Reporting and Prevention (NCC MERP), USA, defines a medication error as ‘any preventable event that may cause or lead to inappropriate medication use or patient harm while the medication is in the control of the healthcare professional, patient, or consumer.’

In other words, a medication error is any deviation from an order for a drug as prescribed by a licensed clinician, such as a physician, physician’s assistant, or nurse-practitioner. The error can be one of planning (for example, if an improper dosage is selected) or one of execution (the prescriber’s intentions are misunderstood). Errors can be made at any point during the process of prescribing and executing a prescription.

Many factors complicate the seemingly straightforward process of prescribing and taking medications.

• First and foremost is the sheer number of drugs, which has grown by leaps and bounds only during the last decade. There is an astounding number of trade and generic names of drugs available (in India), and the number of new entities in the R&D pipeline continues to climb.

With the number of new medications increasing exponentially each year and each drug having its unique indications, prescription writing has become a complex error-prone process.

• The situation is exacerbated by poor nomenclature practices. An astonishing number of prescription medications have names that are spelled (look alikes) or pronounced (sound alikes) in similar ways, yet they have completely different pharmacologic actions. Inadvertently mixing them up can have serious implications for a patient.
• Packaging is another source of confusion. Many drugs are distributed in packages and/ or containers that have similar shapes, colour schemes, or type faces. Such similarities can confound workers operating in healthcare environments already laden with stress.
• The scenario has worsened further by the increase in the volume of prescriptions. More and more aged patients are taking multiple drugs for chronic conditions. Plus, younger patients are taking drugs for longer periods of time; many of these are the called lifestyle drugs used, for example, to curb cholesterol, treat depression, or improve sexual function.
• Patients themselves are often involved in medication errors, simply by failing to comply with their instructions. They may choose not to fill a prescription or fail to take it as directed. They may stop taking a drug before the entire course has been completed. Non-compliance is a profound problem; estimates vary, but around 50 per cent and 90 per cent of patients do not take their medications according to recommended instructions.

We do not know the true frequency of such errors because, in current systems, many are never detected. The crux of these errors is failure of communication and in far too many cases, the underlying cause is the doctor’s handwriting. To many patients, the prescription written by the doctor with pen on paper often looks like a secret code between the doctor and the pharmacist. Unfortunately, these scribbles are sometimes exactly what they appear to be, sloppy handwriting. Many jokes have been made about doctors’ sloppy penmanship, but illegibility is no laughing matter.

In USA, indecipherable or unclear prescriptions result in more than a million calls from pharmacists to physicians, asking for clarification, a time-consuming process that could cost the healthcare system tons of monies a year in wasted tme. At the very least, that process can delay the time until patients receive their medications. At worst, a misread order can lead to injury or even death.

An incorrect understanding of the intended drug, dosage, or route or frequency of administration can quite obviously produce a medication error — not to mention an adverse drug event. Given some doctors’ hurried scribbles, it may be hard for pharmacists to tell whether a zero is preceded by a decimal point or not; if the decimal is misread, the dose ultimately given may be off by an order of magnitude, and the result could be a tenfold overdose. Poor handwriting can blur critical abbreviations for weights, volumes, or units; µg may be confused with mg, again leading to an overdose. An order marked as “qd” (once a day) might be read as “qid” (four times a day).

Prescription writing has always been an area of much debate between physicians, pharmacists and patients. Taking the extra time to decipher a physician’s handwriting may sound like a feasible resolution. Contacting the physician to discuss the prescription is also an alternative. But there is an easier way to ensure that everyone knows what is prescribed and it takes less time than writing out the prescription by hand. It is called computerised prescriptions/electronic prescribing.

Electronic prescribing

While the medical community has made efforts to curb the odds of misinterpretation of handwritten prescriptions, prescription writing remains one of the last and perhaps most important paper transactions in our increasingly computerised society. Most clinicians write prescriptions by hand, utilising memory for drug names, dosage strengths, and directions. It is an archaic system, and it is time to change it by automating the prescribing function.

Several studies in American hospitals have shown that physicians who use a computer order entry program witness reduction in medication error rates. One noteworthy example found a 55 per cent reduction in errors with potential for harm; the program greatly reduced the need for transcription, and it minimised misinterpretations caused by illegibility.

In a study of intensive care patients, a computerised system helped physicians reduce the incidence of allergic drug reactions and excessive drug dosages by more than 75 per cent; the average time patients spent in the unit dropped from 4.9 days to 2.7, slashing costs by 25 per cent. Yet another study concluded that medication errors, though common, result in relatively few ADEs, but those that do result in ADEs are preventable through physician computer order entry.

But computerised order entry is only part of the solution. To be truly effective in reducing medication errors, electronic prescribing must offer even more capabilities and stop errors at additional points in the medication management system. With so many drugs available and so many patients taking concurrent medications, the opportunity for ADEs has never been greater, especially when some patients see a variety of specialists who may be unaware of what their colleagues have already prescribed. Integrating patient and drug information for electronic prescribing offers invaluable benefits to practitioners and other healthcare constituents, such as pharmacists and managed care providers.

Among these benefits are the following:

• Computers can maintain accurate, unbiased, and up-to-date drug databases, which constitute essential tools as the number of approved medications continues to increase.
• Prescribers can receive on-screen prompts for drug-specific dosage information, with reminders to ensure that look-alikes and sound-alikes are not confused.
• Vital patient-specific information, such as overdose warnings, drug interactions, and allergy alerts, can be presented in the course of prescribing, so that potential ADEs that would otherwise go unrecognised can easily be avoided.
• Computers can reduce, even eliminate, the margin for error by flagging pre-existing medical conditions or concurrent medications that would preclude use of certain drugs in individual patents.
• Electronic prescribing can expedite refill requests, once patients are entered into the system.
• Computers can facilitate data exchange to enhance teamwork between clinicians and professionals who represent other parts of the medication management system, such as pharmacists in retail, hospitals, etc.
• Computers can enable practitioners to stay abreast of changes in formularies.
• The use of computers can reduce healthcare costs through time and efficiency savings and by encouraging prescribers to consider lower-cost drug options.

To be concluded in the next issue

The writers are Community Pharmacists, Hindu Pharmacy, Panaji, Goa