Preventing Prescription

Error
“Making it RIGHT, The FIRST TIME’’
JK Penyelaras Keselamatan Pengubatan PTJ &
Cawangan Amalan & Perkembangan Farmasi,
Bahagian Perkhidmatan Farmasi Negeri Terengganu
May 2022
Presentation Outline
1. Objectives
2. Introduction to Prescription Error
3. Types of Prescription Error
4. Contributing Factors Leading to
Prescription Error
5. Strategies to Prevent Prescription Error
6. Take Home Messages
 (1)
OBJECTIVES
Objectives of This Course
1. To highlight the importance of preventing prescription

error.

2. To highlight factors related to prescription error.

3. To explain safe practice in prescribing.

4. To explain prescription safety component in IT system.

 (2)
INTRODUCTION TO
PRESCRIPTION
ERROR
Introduction
• Patient safety is a priority in Ministry of
Health.

• It is important to prevent medication error as

it can lead to patient harm – from mild,
moderate to severe harm including death.

• Medication error may happen during –

Prescribing, transcribing, dispensing or
administering process.

• Hence, it is essential to ensure each process is

done correctly.
 Is Presciption Error Common?
TYPES OF MEDICATION ERROR • Statistics from Ministry of Health showed that total
number of reported medication error has increased
Prescription error Dispensing error Medication error
from 2,818 cases in 2018 to 3,046 cases in 2019. The
statistics include actual error and near miss.

Medication
error • Amongst the various types of medication error,
19% prescription error showed the highest number of
cases (2,878- 53%) followed by dispensing error
Prescription (1,512-28%) and administration error (1036-
19%).
Dispensing error
error 53%
28%

• Fortunately, majority of prescription error managed

to be detected and only 528 out of 2,878 (18.3%)
has led to actual medication error.

(Source: e-IR 2018-2019, Patient Safety Unit, MOH)

 (3)
TYPES OF
PRESCRIPTION
ERROR
What Are The Types Of Prescription
Error?
Error-prone abbreviations

Calculation error

Inappropriate dosage

Wrong route

Wrong frequency

Wrong medication name

Wrong medication – inappropriate polypharmacy

Software problem
 (4)
FACTORS LEADING
TO PRESCRIPTION
ERROR
What Are The Factors Leading To
Prescription Error?
1 Healthcare Professionals associated factors

2 Work Environment associated factors

3 Medicines associated factors

4 Tasks associated factors

Computerized information system associated

5
factors
 Factors Leading To Prescription Error
(1) Healthcare Professionals (2) Work Environment

 Lack of therapeutic training.  Workload and time pressure.

 Inadequate knowledge and  Distraction and interruption
(by both primary care staff and
experience on medication.
patients).
 Inadequate knowledge about
 Lack of standardized
the patient. protocols and procedures
 Inadequate perception of risk.  Insufficient resources.
 Overwork or fatigue staff.  Other issues related to work
environment (e.g: poor lighting,
 Physical & Mental Health issues.
temperature and ventilation).
 Poor communication between
health care, professional and
patient.
 Factors Leading To Prescription Error
•(5) Computerized
(3) Medicines •(4) Tasks
Information System

 Name of medicines  Repetitive systems  Difficult processes

(e.g: sound-alike name for ordering, for generating first
of medication). processing and prescriptions (e.g.
authorization. drug pick lists, default
 Patient monitoring dose regimens and
(dependent on missed alerts)
practice, patient, other  Difficult processes
health care settings,
for generating
prescriber).
correct repeat
prescriptions.
 Lack of accuracy of
patient records.
 Inadequate design that
allows human error
 The MAIN Contributing Factors To
Prescription Error
 System does not
 Lack of knowledge on medication in have user friendly
relation to clinical use.
interface.
 Lack of knowledge on patient safety and
medication safety.
 Lack of knowledge on safe prescribing.
Manual  Not following SOP (Good Prescribing
Practice). Prescription
Prescription  Use of abbreviation. Using IT System
 Illegible handwriting. (Computerized
 “Assume culture” (i.e take action based on Prescribing
assumption without verification). Order Entry)
 Communication breakdown among team
members. Example - Unclear instruction.
 Reluctant to confirm with superior before
prescribing.
 Human factor - staff fatigue, stress,
overwork and heavy workload.
 Prescription Using IT System
(Computerized Prescribing Order Entry)
Example: System provides medication name following dosage
under ‘’Medication Name” and prescriber unable to see full
description before selecting the option
 (5)
STRATEGIES TO
PREVENT
PRESCRIPTION
ERROR
01 Before dispensing

02

03 04
 02 During prescribing
I) Manual Prescription – Do’s and Don’ts

1. Preferably use BLOCK LETTERS when prescribing. Make sure the

writing is legible.
02

03 04
02 During prescribing

02

03 04
 02 During prescribing
2) Do not use ABBREVIATION OR ACRONYM

02

03 04
02 During prescribing

02

03 04
 02 During prescribing
3) Use GENERIC NAME instead of Brand names of the medication.

02
4) Use LEADING ZERO before decimal point. This means write “zero”
before the decimal point.

03 04
5) Avoid TRAILING ZERO after decimal point. This means do not write
“zero” after decimal point.
 02 During prescribing

6) Limit number of
medications in one
medication slip (outpatient),
maximum 5 medications in
02
one slip and make sure to
write a page number for
every prescription slip if it
involves more than 1 page.

03 04
 02 During prescribing
7) Use mcg or microgram and not using symbol (µg).

02
8) When prescribing infusion drug, please write clear instruction
regarding dose, route and rate of infusion.

03
9) Avoid giving verbal order. 04
10) Identify patient correctly using two identifier (example: patient’s
full name, IC No and MRN). ** If patient is unconscious or not
mentally-stable; use IC No, MRN, and face recognition in IC
compared to patients face or input from family members
 02 During prescribing
11) Always take note of allergy, contraindication, body weight and
body surface area for specific medication such as chemotherapy

02
12) Double check with superior or senior colleague if not sure about
the name of medication, dose of medication, route of medication,
frequency of medication and duration.

13) Make sure you have references either manual booklet or phone application that you can
always refer to before making a prescription.

14) It is recommended to prepare a list of common drug with

03 04
dosage, frequency, route in wards and clinics.

15) It is recommended to prepare a list of common

medication or calculation on dosage for high risk patients
such as pediatric patient or patient with renal impairment
in ward and clinics
 02 During prescribing
16) Use generic name/active ingredients instead of brand names of
the medication.

02
17) Use ‘TALL MAN lettering’ in the system for sound- alike medications. Tall man lettering is
the practice of writing certain parts of the medication name in ‘capital letters’, to help
distinguish sound-alike, look-alike medication from one another in order to prevent
medication error. (Refer Appendix 3)

03 04
 03 After prescribing
Medication error can still happen even after correct prescription is
made.
• For instance, failure to cancel existing prescription of specific
02
medication following prescription of new type of medication to
replace the existing medication

1. Monitor medication chart regularly.

2. For in-patient, remember to “CANCEL” existing prescribed medication after completing its
course. Examples: • Antibiotics usually given for certain duration. Doctor must always
remember to “CANCEL” medication in medication chart after completing the course of

04
antibiotics. • New type of medication is prescribed to replace the existing medication.

03 3. Do remember to prescribe “new order” for long standing medication (in-patient).

4. When patient is about to be discharged, make sure the list of medication written on
prescription slip is updated and similar with the list of medications written on Discharge
Note.
Example of Good Prescribing Practice (Out-
Patient)
 (5)
TAKE HOME
MESSAGES
Teamwork & Communication In Preventing
Prescription Error

02
o In order to prevent prescription error, effective communication
and good teamwork are essential.
o Doctors, pharmacists and paramedics need to work together as
a team.
o Everyone needs to listen to each other’s concern, opinion and
recommendation regardless of heirarchy.

03 04
 Thank You
Sekalung penghargaan kepada semua Penyelaras MedSafe PTJ
2022 di atas sumbangan yang diberikan.

Jutaan terima kasih juga kepada semua anggota farmasi yang

terlibat dalam penghasilan modul ini.