Body and Introduction
According to CNA's Nurse Practitioner Claims Study (1998–2008), 17.7% of malpractice claims against nurse practitioners (NPs) involved medication. Among the most common errors were prescribing the wrong medication, prescribing the wrong dose, failing to properly discontinue a medication, and prescribing an incompatible, contraindicated, or interactive medication. Several NPs have been investigated and disciplined by boards of nursing for their prescribing practices. Usually, these cases involve prescribing opioids for non-cancer pain.
Here are 10 safety-related habits to incorporate into your practice to avoid mishaps when prescribing.
Obtain, record (preferably on every page of the patient record, along with the patient's name), and update (preferably at every visit) the patient's drug allergies.
Keep every patient's medication list up-to-date and in a consistent place in the medical record. This system helps to avoid prescribing duplicative medications, missing potential drug interactions, prescribing contraindicated medications, overmedicating because refills are ordered too soon, and making errors on refill dosages.
Include in the medication record all prescriptions written (name, dose, number, refills), samples dispensed, date written, diagnosis for which medication written, special instructions given, and a check-box indicating whether written instructions were provided. Also include a space for noting when refills were ordered, when medication changes were ordered and the nature of the change, and a space for the provider's initial making the change or ordering the refill.
Include in each entry the name of the medication, dose, number dispensed, and instructions when recording medications ordered and refilled in the progress notes. Do not simply record "Refill meds," which is ambiguous if a patient is taking more than 1 type of medication.
At each visit, ask the patient what medications he/she is taking. It is easy to forget that patients see more than 1 nurse practitioner or physician. Ask the patient to include over-the-counter and prescription medications and herbal remedies. An even better habit is to ask patients to bring all medication bottles at each visit. To conserve time, have a nurse or assistant record the list when recording the chief complaint and vital signs. Have a nurse or assistant periodically conduct pill counts to see whether the patient is taking the medication as prescribed.
When ordering a new medication, inform the patient about potential side effects and document that the patient has been so advised. Example: "Discussed side effects, dosing, start date, what to do if pills missed."
Open a pharmaceutical reference book or log on to Epocrates.com and read the patient the contraindications, drug interactions, pregnancy precautions, and possible side effects. Review for yourself the indications, dosing, interactions, and precautions.
Provide printed patient medication information forms that list indication, dosing, potential side effects, and drug interactions for often-prescribed medications. These are available from commercial publishers, pharmaceutical representatives, or may be written by the NP or physician. For quick recording, the information sheets may be numbered and recorded by number, such as, "PMI [Patient Medication Information] 007."
Rule out pregnancy before prescribing certain medication to females capable of becoming pregnant.
If a patient exhibits "nonadherence" to a treatment plan for chronic non-cancer pain or is not improving on the current treatment, or if the practitioner suspects that the patient is abusing or diverting medication, refer the patient to a pain specialist for consultation or evaluation/management. Don't keep prescribing opioids without evidence that the treatment is working.
Journal for Nurse Practitioners. 2011;7(7):600-601. © 2011 Elsevier Science, Inc.
Cite this: 10 Habits to Adopt to Avoid Prescribing Errors - Medscape - Jul 01, 2011.