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Reducing Medication Prescribing Errors in a Teaching Hospital

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Background: Medication errors occur frequently, result in significant morbidity and mortality, and are often preventable. A multifaceted intervention was conducted to reduce prescribing errors in handwritten medication orders written by house staff.

Methods: A before-and-after design was used to evaluate the intervention—which included grand rounds, an interactive presentation for house staff, and reminders (a checklist, chart inserts, and requests for clarification)—and targeted 20 safe prescribing behaviors.

Results: At baseline, prescribing errors were more common among surgical house staff than medical house staff (1.08 errors/order versus 0.76 errors/order, p < .001). Only 1% of orders contained an overt error, but 49% were incomplete, 27% contained dangerous dose and frequency abbreviations, and 17% were illegible. Postintervention, the mean number of prescribing errors per order decreased for surgical house staff from 1.08 (standard deviation [SD], 0.23) to 0.85 (SD, 0.11; p < .001), with a more marked effect for house staff who attended the didactic portion of the intervention. In addition, the mean number of the more significant errors per order decreased from 0.65 (SD, 0.19) to 0.45 (SD, 0.13; p < .001), and significant decreases occurred in the proportion of orders that were incomplete, were illegible, and contained an overt error. However, prescribing errors per order increased in orders written by medical house staff from 0.76 (SD, 0.14) to 0.98 (SD, 0.11; p < .001).

Discussion: The intervention was associated with a modest improvement in the quality of medication orders written by surgical house staff. To reduce prescribing errors, multilevel interventions are needed, including training in safe prescribing for all physicians. Such training may need to be started in medical school and augmented and reinforced throughout residency.

Document Type: Research Article

Publication date: September 1, 2008

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  • Published monthly, The Joint Commission Journal on Quality and Patient Safety is a peer-reviewed publication dedicated to providing health professionals with the information they need to promote the quality and safety of health care. The Joint Commission Journal on Quality and Patient Safety invites original manuscripts on the development, adaptation, and/or implementation of innovative thinking, strategies, and practices in improving quality and safety in health care. Case studies, program or project reports, reports of new methodologies or new applications of methodologies, research studies on the effectiveness of improvement interventions, and commentaries on issues and practices are all considered.

    David W. Baker, MD, MPH, FACP, executive vice president for the Division of Healthcare Quality Evaluation at The Joint Commission, is the inaugural editor-in-chief of The Joint Commission Journal on Quality and Patient Safety.

    Also known as Joint Commission Journal on Quality Improvement and Joint Commission Journal on Quality and Safety
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