Off-Label Prescribing
Prescribers should clarify the purpose of a medication, especially when a drug has multiple uses or is being used "off-label."
A physician recently prescribed amitriptyline to an elderly woman to treat neurogenic pain syndrome, but didn't explain why it was being prescribed. The dispensing pharmacist counseled the patient, describing the medicine as an antidepressant. The woman became angry, refused the medication, and accused her physician of believing her pain to be "all in her head." The woman's distress could have been avoided with better communication.
Many adjunctive medications are used for off-label indications, or in unusual doses, for palliative care. Include the indication on outpatient prescriptions or hospital orders. Prescription blanks are available with icons that describe a drug's purpose.
Insulin Therapy Complexity
Data show that insulin errors occur frequently and cause significant patient harm. Insulin therapy has always required thoughtful management; however, management is now more complex.
Insulin onset of action varies widely (from minutes to 8 hours), making administration and the relationship to mealtime confusing. The ISMP has received reports of patients developing hypoglycemia because they haven't eaten within the required time frame, especially after receiving ultrashort-acting insulin lispro (Humalog) or insulin aspart (NovoLog). This also occurs when insulin is ordered to a standard dosing schedule, such as "every morning," and not prescribed to a specific mealtime.
Patients may receive widely variable doses and more than one insulin type at a time. Confusion and failure to discontinue previous insulin when switching to a new product may go unnoticed until harm occurs. Errors were recently reported when several patients were hospitalized after taking both humalog and regular insulin or lantus insulin along with twice daily NPH insulin.
If clinicians are confused, imagine the confusion of the patients. Other causes of complexity (for example, using "u" for unit and improper mixing) leave no doubt that insulin is a high-alert drug that is prescribed, dispensed, and administered via error-prone processes and to patients who are at risk if an error occurs.
Suggestions to avoid the confusion caused by insulin therapy:
* Obtain an accurate history of your patient's insulin therapy[forms light horizontal]ask questions to detect possible confusion between insulin products. Tell your patients to bring their insulin to you for validation, if possible.
* Store and dispense insulin safely.
* Communicate prescriptions clearly-use the entire product name and write out "units." List concentration and dose in units and volume if a nonstandard insulin concentration is needed. Use verbal orders only when necessary.
* Consider your patient's mealtimes and explain the relationship between insulin and meals. Establish a sliding scale of insulin coverage during illness.
* Educate your patients[forms light horizontal]explain how to prevent and treat hypoglycemia. Reinforce that physical activity and snacks affect glucose levels. Explain how to handle travel and illness. Have your patients demonstrate glucose monitoring skills and insulin administration, including measuring the correct dose.
* Gauge the patient's insulin response by obtaining blood glucose levels. Pay special attention to the patient at risk for hypokalemia and hypoglycemia. Patients with renal or hepatic impairment may require a reduction in total daily doses of all insulin.
"AD" Abbreviation Dangers
When "ad" (aura dexter) is handwritten, it can easily be confused with "od" (oculus dexter), and a patient may risk getting an otic medication into the right eye instead of the right ear. In a recently reported error, a physician ordered "auralgan two drops AD." The nurse administered the drops in the patient's right eye. When the error was discovered, the eye was flushed and no permanent harm occured. "AS" (left ear) or "AU" (each ear) may also cause similar problems.
Another "ad" error was recently reported. A pharmacist abbreviated "as directed" as "AD." The pharmacy technician misinterpreted the directions "5 ml TID AD" and typed "one teaspoonful three times a day in right ear." AD is an abbreviation everyone should avoid.
Once-a-Week Dosing
Fatalities in patients prescribed a once-a-week dose of methotrexate (for example, for rheumatoid arthritis, asthma, psoriasis, inflammatory bowel disease) have been reported to the Institute for Safe Medication Practices (ISMP). As few medications are dosed weekly, methotrexate has been accidentally prescribed or dispensed daily. Verify proper dosing, confirm the dosing schedule on records and prescription labels, and educate staff and patients. Prescribe unit-of-use packs.
Medication Error Trifecta
A confused, agitated, and combative patient was admitted to an ED with severe nausea, vomiting, and a reported seizure. His initial diagnosis was viral gastroenteritis.
The patient had been taking Wellbutrin (bupropion) for depression. Six weeks before admission, his physician gave him new prescriptions for all his medications; this time, using generic names. Unfortunately, the patient continued taking Wellbutrin and also started taking the new prescription for generic bupropion. About the same time, he attended a smoking cessation program where another physician gave him a prescription for Zyban (bupropion). The physician prescribing the Zyban didn't have a list of the patient's other medications. He was, therefore, taking Zyban, bupropion, and Wellbutrin at the same time.
The ED staff, unit nurses, pharmacists, attending physician, and consultant neurologist all missed this error. Fortunately, the error was discovered by a 3rd year medical student.
Multiple names for products increase the likelihood of duplicate or triplicate therapy. Duplication may also occur when branded generic products are available from different manufacturers, when the same drug is dispensed from two pharmacies under two different names, or when one prescriber orders a product by its brand name and another prescribes it by its generic name.
Alert your patients and teach them the generic and brand name of prescribed drugs. Encourage your patients to keep a medication list and to bring it with them when they seek health care. Suggest having prescriptions filled at the same pharmacy if possible.
Patch "Overdose"
Patients may misapply Duragesic (fentanyl) patches. In a recently reported case, a confused, elderly woman applied six patches at one time "wherever it hurt" on her body, resulting in opiate toxicity. Prior to prescribing, a clinician needs to assess the patient's ability to understand proper dosing, administration, and disposal.
Avinza/Invanz Confusion
Always include dose and administration route when communicating prescription orders for Invanz (ertapenem), which may be confused with Avinza (morphine sulfate extended release). Invanz has also been mistaken as "IV Vanc." Write out fully[forms light horizontal]don't use "vanc" for vancomycin or statements such as "put the patient on Avinza" or "start Avinza."
Femara/Femhrt Mix-up
An oncologist prescribed Femara for a postmenopausal woman with recurrent breast cancer; however, the patient received Femhrt. Both drugs are prescribed to women for conditions related to menopause and both have names that look and sound similar. Including the strength when prescribing Femara may help differentiate it from Femhrt.
Watch Out for Computer Translations
Software translation problems can lead to omitted characters or the display of incorrect characters. For example, the character for the Greek letter "mu" (micro) does not always translate well or might not be seen at all in certain word processing programs. Avoid using symbols when expressing drug doses in word processing programs and review carefully. The handwritten "mu" should be avoided because it can be misunderstood as milligram.
Health Literacy
Poor "health literacy" is not an obvious problem, but it's more prevalent than many assume. People who cannot read or understand health information are often ashamed and hide the problem.
Researchers report poor reading skills in some of the most poised and articulate patients. Assume that everyone has a health literacy problem. People at all literacy levels prefer simple, straightforward instructions and written materials.