Articles: Medical Errors

What did that order say?

The prevalence of medication errors in hospitals and other healthcare organizations is a topic that has in recent years evolved into a major national health concern. Medication prescription and administration are routine aspects of medical, nursing, and pharmaceutical practice, yet have the potential to result in permanent injury or death. Some of the most successful litigation against healthcare providers concerns medication errors. It is easier to establish the standard of care for medication prescribing, dispensing, and administration than it is for many other aspects of medical practice. This article focuses on the risks associated with interpreting medication orders written by physicians and nurse practitioners. The nurse is expected to know enough about the medications that are to be given to the patients in order to question erroneous orders or identify areas of concern or inaccuracy. The pharmacist is expected to interpret the order and dispense the correct drug and dosage. A medication error may have no impact on the patient; on the other hand, a serious error can kill a patient.

A 1979 study showed that it was difficult to accurately interpret about half of all physicians’ handwritten orders.¹ With direct physician computer order entry limited to a small number of medical facilities, not much as changed in the last 25 years. The difficulty in interpreting handwriting wastes nursing staff time when nurses consult each other to come up with a best guess about an order before calling the prescriber for clarification. Even well-written orders may be misinterpreted because of variations in the shapes of characters or if the tail or loop of handwritten letters above or below the order interferes with interpretation.² A line may interfere with the observation of a decimal point. The order below for 20.4 mg of Cisplatin (chemotherapy) was interpreted as 204 mg, resulting in a ten fold overdose and the death.

Unclear handwriting led to a ten fold overdose of Zanaflex, shown below. It was ordered as 2 mg but interpreted as 20 mg. Fortunately, this did not result in harm to the patient.

Confusing abbreviations may also result in medication errors. The Joint Commission on Accreditation of Healthcare Organizations (JCAHO) has put teeth into a requirement that healthcare providers not use dangerous abbreviations in medical records. JCAHO accredits hospitals, nursing homes and a broad range of other healthcare organizations. Beginning in 2002, JCAHO identified national patient safety goals for healthcare organizations seeking accreditation by JCAHO. (See 2004 National Patient Safety Goals.) One hundred percent compliance in all forms of clinical documentation with a reasonably comprehensive list of prohibited dangerous abbreviations, acronyms, and symbols is the long term objective of this requirement. Organizations surveyed in 2004 will be considered to be in compliance with this objective if the following conditions are met:

• Use of any item on the list is sporadic (less than 10 percent of the instances of the intended term are abbreviated or symbolized) AND
• Whenever any prohibited item has been used in an order, there is written evidence of confirmation of the intended meaning before the order is carried out AND
• The organization has implemented a plan for continued improvement to achieve 100 percent compliance by the end of 2004.³

1. U (for unit) can be mistaken for zero, four, or cc. For example, Regular Insulin 10 U has been interpreted as Regular Insulin 100 units. U should be written out as unit.

2. IU (for international units) has been mistaken for IV (intravenous) or 10. For example, Vitamins D, E, and A, ACTH, and PPD skin tests are all ordered in international units. IU should be written as “international unit.”

3. Q.D. (every day) and Q.O.D. (every other day) are mistaken for each other. The period after Q. in Q.D. can be mistaken for an “I”, making this Q.I.D for four times a day. For example, Librium 50 mg Q.D., if interpreted as Librium 50 mg QID, would result in a four fold overdose. Q.D. and Q.O.D. should be written out as “daily” and “every other day.”

4. Trailing zeros are written as X.0 mg with the 0 following the decimal point. The lack of a leading zero occurs when an order is written as .X mg. The risk is that the decimal point can be missed. Healthcare providers should never write a zero by itself after a decimal point (X mg is correct) and always use a zero before a decimal point (0.X mg is correct.) The Cisplatin overdose could have been avoided if the person who calculated the dose had rounded it off to 20 instead of keeping it as 20.4 mg.

5. Abbreviations for morphine sulfate) MS and MSO4) and magnesium sulfate (MgSO4) can be misinterpreted. The prescriber should write “morphine sulfate” or “magnesium sulfate.” 

Effective 4/1/04, each organization must have additional “do not use” items of their lists. Both JCAHO ³ and the Institute for Safe Medication Practices (www.ismp.org) ⁴ provide lists of dangerous abbreviations.

Practice points
During the discovery phase of litigation, ask for the facility’s “do not use list.” When evaluating a medication error, determine if the order involved one of the “do not use” items. If the error involved misinterpretation of an item on the “do not use” list, evaluate the prescriber’s order to determine if there is documentation that the order was clarified or confirmed before the order was carried out. An item on the “do not use” list should not be used in any of its forms- upper or lower case, with or without periods.  The “do not use” list applies to all forms of handwritten, patient-specific documentation through 2004, such as progress notes, consultation reports, nursing notes, and all other clinical documentation. After 2004, the “do not use” list also applies to preprinted forms which include the prohibited items.  

1. Anonymous. A study of physicians’ handwriting as a time waster. JAMA 1979: 242: 2429-30
2. In the long run, penmanship classes for doctors won’t do much for patient safety, www.ismp.org, accessed 1/10/04
3. “Do not use” list required in 2004, www.jcaho.org, accessed 1/10/04
4. ISMP list of error-prone abbreviations, symbols, and dose designations, www.ismp.org, accessed 1/10/04

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Med League Support Services, Inc. supplies expert witnesses who evaluate cases for defense and plaintiff attorneys. We also attorneys by: Screening cases for merit, analyzing medical records, locating expert witnesses, preparing demonstrative evidence including time lines, chronologies and medical illustrations.