Medication error reporting through prescription auditing

Dr M C Joshi

Bringing information on patterns of existing practice together with information on appropriate practice is an essential component of efforts to improve healthcare. This is possible only when each and every prescription in the hospital is audited by a prescription auditing team. The process of prescription auditing in its broad sense include prescription monitoring, drug utilisation studies, prescription pattern studies, study of prescription habits of doctors, adverse drug reaction monitoring, drug interaction monitoring, criteria based prescription auditing and many other activities.

But the grassroot activities include checking the prescription for drug name (brand name or generic), strength, formulation, dose, route of administration, frequency, duration of treatment and drug allergies. Adverse Drug Reaction (ADR) reporting could also be confirmed by a search for prescriptions containing tracer drugs e.g. Avil injection and Effcorlin injection

Why is prescription auditing needed?

According to studies cited in the Institute of Medicine report, To Err Is Human: Building a Safer Health System, 44,000 to 98,000 Americans die each year as a result of medical errors. This statistic is associated with a cost of USD 17 to USD 29 billion and ranks medical error the eighth-leading cause of death in the US. The Joint Commission on Accreditation of Healthcare Organisations (JCAHO) states that some of the most common medical errors are related to medication delivery.

A medication error is defined by the National Coordinating Council for Medication Error Reporting and Prevention (NCC MERP), 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 health care professional, patient, or consumer”.

In Indian scenario, a proper reporting of medication errors in the hospital is not available, but out of all visits to the medical emergency department- six per cent are drug-related. ADRs accounted for 45 per cent of all ADEs. Of all ADE-related visits, 52 per cent and of all ADE-related admissions, 55 per cent were considered preventable. Voluntary Consumer Action Network, in a recent survey of 200 prescriptions, confirmed irrational drug use and has warned that doctors found to be mis-prescribing would be sued in consumer courts for medical negligence. The fast growing rates of medication errors all over the world decides the need for starting a routine prescription auditing in all the multispeciality and tertiaty healthcare centres in India.

Methods of prescription auditing

The method used for prescription auditing depends upon purpose for which it is carried out. Since, a routine auditing of prescription is not yet started in India, it is carried out to study certain specific group of drugs namely- antibiotics, anti-cancer drugs, anti-hypertensive drugs, analgesics (NSAIDS and opioids), anti-ulcer drugs, geriatric medicines for the purpose of doing a drug utilization study, prescription pattern studies, rational drug use studies and various other types of studies. These studies are very helpful in collecting datas regarding prescription habits of doctors, the comparison of efficacies of different drugs, the adverse effects associated with a drug or with a particular brand name. The method that is developed in our hospital is of routine online screening of all the prescription drugs, indented by the nursing staff, to the hospital pharmacy along with the prescribed information regarding the drug name (brand names), strength, formulation, doses, route of administration, frequency and duration of treatment.

Standard Operative Procedure

1.Doctor prescribes medicines on the prescription order sheet.

2. Indents made by the nursing staff (drug order to pharmacy through an online transcription).

3. The indents contain – drug name, strength, formulation, doses route of administration, frequency & duration of treatment.

4. Indents checked by the clinical pharmacist (using softwares). Pharmacist should read it carefully and check the drug name (generic / brand), strength, formulation, doses, route of administration, frequency and duration of intake.

5. The clinical pharmacologist specifically screens the indents made from the ICUs, since these patients are more prone for requiring doses adjustments, drug interactions and adverse effects (cases of altered pharmacokinetics and pharmacodynamics) using the online lab module. If the pharmacist is unsure about any drug, he should get it verified with the clinical pharmacologist.

Note: In case any correction / suggestions / recommendation/need for an alternate therapy is felt by the clinical pharmacologist, a verification call is given to the doctor- prescriber.

Outcomes of Prescription Auditing

Medication Errors

Medication errors reported through prescription auditing could be because of the mistake done by a doctor, nurse or the pharmacist. Medication errors are basically of two types: intercepted errors and actual errors, on the basis whether they reach the patient or not.

Both the types of errors are further divided into four categories-

• Prescription error
• Administration error
• Transcription error
• Dispensing errors

Except administration error, rest all types of errors could be rectified by prescription auditing. The administration error could only be rectified by hospital rounds, which are also essential for adverse drug reaction monitoring. Prescription errors which are corrected and prevented by prescription auditing team are called as intercepted error.

Type of Error and Criteria

Prescription Errors

1.No route specified
2.As-needed order without an indication
3.Drug is indicated but the dose is inappropriate
4.As-needed order without a time interval
5.Dose change ordered without discontinuation of previous order
6.Order is illegible
7.Order is incomplete in specifying doses or frequency

Transcription Errors

1.Order is not transcribed at all
2.Order is transcribed incorrectly
3.Allergy is not documented on the medication administration record
4.Allergy is not documented on the order sheet

Administration Errors

1.Scheduled dose is not documented as administered
2. Drug is administered without a physician order
3. Dose missed because of late transcription
4. Order is incorrectly entered in the pharmacy computer

Dispensing Errors

1. Wrong drug or dilution dispensed
2. Wrong preparation dispensed

The intercepted errors (the error which has not reached the patient) are documented by preserving a copy of the indent. The actual errors or an “error of omission”, which does reach the patient inspite of auditing, are reported on a proper format called as quality variance report.

Medication Error Index

This is required for categorising medication errors.

No Error

Category A: Circumstances or events that have the capacity to cause error.

Error, No Harm

Category B: An error occurred but the error did not reach the patient (An error of omission does reach the patient).

Category C: An error occurred that reached the patient but did not cause patient harm.

Category D: An error occurred that reached the patient and required monitoring to confirm that it resulted in no harm to the patient and/or required intervention to preclude harm.

Error, Harm

Category E: An error occurred that may have contributed to or resulted in temporary harm to the patient and required intervention.

Category F: An error occurred that may have contributed to or resulted in temporary harm to the patient and required initial or prolonged hospitalisation.

Category G: An error occurred that may have contributed to or resulted in permanent patient harm.

Category H: An error occurred that required intervention necessary to sustain life.

Error, Death

Category I: An error occurred that may have contributed to or resulted in the patient death.

ADR Monitoring

The adverse drug reaction is monitored by searching for the tracer drugs like Avil injection and Effcorlin injection and checking the indications for which they were prescribed, during the hospital rounds. If any adverse drug reaction occurs it is reported on an ADR reporting form. All the details regarding the drug e.g. brand and generic name, doses, route of administration should be documented. The ADR should be described according to the signs and categorized according to the severity. The type of reaction should also be noted down (Whether Type I, II, III or IV).

Conclusion

The process of prescription auditing is a type of vigilance activity, which is very beneficial for the hospital in terms of reducing the burden because of medication errors and increasing the rate of patient recovery and discharge from the hospital. A zero medication error is an impossible thing to achieve because we are humans and not machine. So, the only way to get rid of medication errors is a thorough scrutiny of all the steps involved in medication process and prescription auditing is done at a very important step, ie before the medication are dispensed. This should be implemented in all the hospitals in India, where the patient load is too high, to be properly handled.

The writer is a clinical pharmacologist at Indraprastha Apollo Hospital, New Delhi