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Program Manager Health Literacy and Learning Program Northwestern University 750 North Lake Shore Drive, 10th Floor Chicago, Illinois 60611 fax 312/503-2777stacy-bailey{at}northwestern.edu
Assistant Professor Feinberg School of Medicine Northwestern University
Senior Research Associate Faculty Emory University Center on Health Outcomes and Quality Atlanta, Georgia
Professor Division of General Medicine School of Medicine Emory University
Assistant Professor Feinberg School of Medicine Northwestern University
Published Online, January 6, 2009. www.theannals.com, DOI 10.1345/aph.1L388
To compare handwritten and electronically generated prescription drug instructions, we assessed the variability of medication instructions and their compliance with Joint Commission and NCC MERP recommendations at the point of prescribing for 3 medications with the common dosage instruction, "Take one tablet a day." We compared 85 handwritten prescriptions from a hospital in the Southeast with 1326 electronically generated prescriptions from an academic practice in the Midwest. Institutional review boards at each site approved the study. Investigators reviewed instructions to determine whether Latin was used and to create a list of unique Sig. messages. A Sig. message was considered unique if it differed from others in terms of wording (tablet vs capsule), use of numeric characters (one vs 1), or phrasing (once daily vs one a day).
The majority (61%) of handwritten prescriptions did not adhere to Joint
Commission and NCC MERP recommendations to avoid Latin phrases. In contrast,
only 1% of electronically generated prescriptions contained Latin
abbreviations. Electronically generated prescriptions also had less
variability than handwritten prescriptions; the 2 most common instructions for
electronic prescriptions (1 TAB orally every day and 1 TABLET DAILY) accounted
for 69% of all prescriptions, while the 2 most common handwritten
prescriptions (
QDay and
daily) accounted for 18% of all
prescriptions. Most electronically generated medication instructions (93%)
were default Sig. messages, which automatically appear within the text box in
the electronic health record (EHR). Therefore, variability in the
electronically generated Sig. messages was a product of variability in the
default Sig. messages. The same medication often had multiple preset Sig.
messages listed in the EHR depending on drug strength. Sig. messages also
varied greatly between drugs despite the same instruction. Physician reliance
on defaults suggests that this variability would decrease if consistent
defaults were used for all doses, across all drugs as applicable.
This study has 2 major limitations: we examined only 2 sites, and our findings may not be generalizable to other locations. Only 85 handwritten prescriptions were available for analysis, which may have impacted our main findings.
A recent 2008 IOM report has provided clear evidence to support best practices for drug labeling.3 The use of EHRs offers an opportunity to adopt these practices and reduce instruction variability and the use of Latin terminology. Efforts should be taken to set standards for the writing of Sig. messages to promote patient safety and improve patient understanding of medication instructions, thereby reducing the number of preventable adverse drug events.
References
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