CLINICAL PHARMACOLOGY

Common prescribing errors rather than the mechanism of prescription writing. A considerably
smaller survey in the Netherlands found that 60% of prescription

and how to prevent them orders contained at least one error, usually with regard to tran-
scription; the authors identified over 100 avoidable adverse
events, in 90% of which patients experienced ‘temporary harm’.
Michael Schachter
The National Patient Safety Agency in the UK collected data on
40,000 and estimated that about 15% were associated with slight
harm and 5% with more serious harm, but probably no more than
half of these errors were prescribing errors. A very large US survey
Abstract
Prescribing errors are a subset of medication errors and are especially of community pharmacies found that 1.7% of prescriptions con-
important because they are usually avoidable. Their true incidence is diffi- tained errors. Ideally, one would like to quote a systematic review
cult to assess, but they may occur in 2% of prescriptions in both primary or meta-analysis but attempts to do these have failed with
and secondary care. However, in only a small minority of these are there absurdly wide ranges estimated for the incidence of errors.
serious consequences for the patient, largely because, at least in the UK, However, a very extensive systematic survey of the literature by
many errors are detected and corrected by clinical pharmacists. Lack of Dornan’s group arrived at a figure of about 7%, based mainly on
knowledge about medications is a significant source of error, as are data from the UK and the USA.3 The different estimates are largely
distraction, fatigue and transcription errors in prescriptions. Improved the consequences of differences in definitions and other method-
training of prescribers at both undergraduate and postgraduate level is ology: the methodological issues have been comprehensively
essential, though not in itself sufficient, to bring about improvements reviewed by Ferner.4 Fortunately the number of truly serious,
in patient safety, and the proposed UK national prescribing assessment even life-threatening errors is a small fraction of this total.
should provide impetus for this. Computerized prescribing can reduce
the rate of errors but does not eliminate them, and can introduce new What is the nature of prescribing errors?
types of error unless carefully managed. The conclusions of studies to date5e9 can be summarized broadly
under the following headings.
Keywords computerized prescribing; medication errors; prescribing
errors Incorrect or irrational drug choices
These may be due to misdiagnosis, failure to understand the
underlying clinical condition, ignorance of the drugs available,
Medications are dangerous. As the 16th century German physi- such as the choice of an inappropriate antibiotic for a specific
cian, Paracelsus, put it, all medications can be poisons, it just infection, or ignorance of their pharmacology, such as the use of
depends on the dose. Errors can and do occur at every step in the a b-blocker in a patient known to have asthma. In fact Dornan’s
process from the mind of the prescriber to administration to the wide-ranging survey of the causes of prescribing errors pointed
patient and beyond. The process is more or less the following: to ignorance, of the drug or the patient, as the single most cited
 the therapeutic objective is determined cause of error.8
 the medication is chosen
 the route, formulation, dosage and frequency are decided Ineffective prescribing
 the prescription is written This may involve medications that, although not harmful, do not
 the medication is dispensed treat the patient’s clinical problem. Homeopathy is an example
 the medication is administered or taken with which most physicians and pharmacologists would agree.
 the effects of the medication are monitored. The obvious danger is that such practice may delay or even
This article is concerned with only the first four of these steps; prevent the patient receiving effective therapy.
a great deal of evidence suggests that these represent not only the
most frequent but the most likely sources of preventable error. Underprescribing
We now need to consider the frequency of prescribing errors, This is probably less of a problem nowadays than its opposite,
their nature, and how they can be prevented or at least overprescribing. Yet there is evidence that patients with chronic
minimized. heart failure are not always receiving angiotensin-converting
enzyme inhibitors or angiotensin receptor blockers despite the
How frequent are prescribing errors? huge body of evidence favouring these therapies. Loss of clinical
effect can also result from substitution of an alternative drug
One would think this was an easy question to answer, but it is
within the same group without appreciation of relative potency;
not.1 A survey in a London teaching hospital in 2002 found an
for example, in a patient whose systolic pressure rose from 120 to
incidence of 1.5% in over 36,000 prescriptions over a 4-week
over 150 mmHg after losartan 50 mg daily was substituted for
period, about a quarter of which were considered to be serious.2
candesartan 8 mg daily.
Over 50% of the serious errors involved prescribing decisions
Overprescribing
This may involve prescribing a drug for which there no need, the
Michael Schachter BSc MB FRCP is a Senior Lecturer in Clinical Pharma- most familiar example being antibiotics for patients who almost
cology at Imperial College, St Mary’s Hospital, London, UK. Conflicts of certainly have a viral infection. In this case the prescriber is
interest: none. usually responding to patient pressure, without regard for

MEDICINE 40:7 394 Ó 2012 Elsevier Ltd. All rights reserved.

increasingly widespread antibiotic resistance. Overprescribing from the development of clinical pharmacy and the involvement of
may also involve excessive dosage. The London hospital survey clinical pharmacists in scrutinizing prescriptions before medicines
mentioned above found a patient for whom captopril 250 mg had are administered. It is likely that the majority of incorrect and
been prescribed instead of 25 mg: fortunately this dose was not potentially dangerous prescriptions are intercepted and corrected as
administered. A patient at a hospital in southern England was a result. However, it would be extremely complacent for prescribers
less fortunate: a dose of digoxin 250 mg (rather than 250 mg) to rely on this form of rescue; they should try to prevent the need for
proved fatal. It was not clear whether this was due to illegible it. So what can and should be done?
writing or ignorance of the correct dose.  Improved training in the principles and practice of safe
It is also possible to approach these problems from a different, prescribing for medical undergraduates and other potential
more psychologically based, perspective. prescribers. At the time of writing the UK Medical Schools
Council and the British Pharmacological Society are
Knowledge-based errors proposing to introduce a compulsory, national prescribing
These usually take the form of incorrect or irrational prescribing but assessment for all medical undergraduates in 2014, though
may be subtler and may involve a drug interaction. For instance, the its legal status is unclear. This represents what some would
prescriber may be unaware that carbamazepine will induce the consider a belated recognition that graduates often have
metabolism of warfarin, leading to a large reduction in the inter- a limited knowledge of basic and clinical pharmacology, and
national normalized ratio and increased risk of thrombosis, or that the practicalities of prescribing. It surely makes sense that
thiazide diuretics reduce the clearance of lithium, leading to future doctors should have a sound knowledge of the
dangerous toxicity. In a different context, they may prescribe co- essential but dangerous activity of prescribing. This educa-
amoxiclav to a patient known to be allergic to penicillin. tional process should include a basic understanding of the
These examples underline the importance of an accurate and nature of medication and, particularly, prescribing errors.
comprehensive drug history, including definite and suspected All prescribers should be aware of the risks associated with
allergies. Patients may also be taking medications (or supposed specific drugs and patient populations, notably the elderly.
medications) that have not been prescribed. A patient may be  The reinforcement of these principles and practices in
taking St John’s wort, purchased at a health food shop, for mild postgraduate education, including informative feedback
depression (with good effect), without realizing that it could from regulatory bodies on particular issues where there are
induce metabolism of prescribed statin. emerging problems and dangers.
 The provision of working environments where the likelihood
Rule-based errors of error is minimized. This includes adequate supervision by
These result from failure to adhere to essential procedures, such as senior colleagues, who should be less likely to generate the
the necessity for therapeutic monitoring of aminoglycoside antibi- types of error noted above; an environment where
otics such as gentamicin. Failure to do this often enough, or failure prescribers who make errors (though not those who are
to act on the results, can lead to irreversible vestibular damage. clearly negligent) can receive guidance and feedback without
fear of disciplinary action (unless they are clearly negligent or
Action-based errors (slips)
ignore repeated warnings); and an environment where error
These are often due to distraction or fatigue, as in a case where
becomes less likely through avoidance of excessive hours and
two identical prescriptions for diazepam were written on the
fatigue. Although the European Working Time Directive
same prescription chart e and duly administered. In the past,
supposedly promotes this, the reality is that it has led to shift
chlorpromazine has been prescribed instead of chlorpropamide,
working, involving intermittent night shifts, which are
and vice versa, but happily both these drugs are now obsolete.
known to impair concentration and judgement.
Memory base errors (lapses)  Increased harmonization and simplification of prescription
This may consist simply, but dangerously, of omitting a drug that forms in secondary care. Prescribers moving from one
the prescriber is fully aware should be given, for instance hospital to another will find a wide variety of forms, and at
a corticosteroid or an antibiotic. In the case of documented drug least while they are getting used to the new ones the
allergy, the prescriber may be fully aware of the problem but possibility of errors may increase.
forgets it at the time of writing the prescription. One further major solution, or possible solution, needs to be
considered.
Transcribing and other writing errors
The illegibility of doctors’ handwriting is legendary, but the Electronic prescribing: the problem solved?
outcomes in prescribing can be serious. Nurses and pharmacists
Electronic prescribing is very widely used in the USA and increas-
are empowered to refuse to administer a drug whose name
ingly so in the UK. It has obvious appeal: not only should it provide
cannot be deciphered, but problems can arise if these profes-
a database for prescribing that can be analysed and reviewed for
sionals make assumptions about what has been written.
a range of different purposes, but it should counteract a number of
potential errors: warning about and blocking unrealistic and
What are the solutions?
dangerous doses; warning about problematic drug interactions; and
Before considering these it is worth noting that prescribers (and warning about allergies (if they have been documented). Many
patients), at least in the UK and probably many other countries, are different systems are available and it is clear that their performance
protected from the consequences of these errors. This has resulted varies widely. A study by Kanji and colleagues showed that the error

MEDICINE 40:7 395 Ó 2012 Elsevier Ltd. All rights reserved.

rate associated with different systems varied from 5 to 18%.10 2 Dean B, Schachter M, Vincent C, Barber N. Prescribing errors in
Overall, the error rates were not dissimilar to those with conven- hospital inpatients: their incidence and clinical significance. Qual Saf
tional prescribing and included errors of omission of information, of Health Care 2002; 11: 340e4.
conflicting and unclear information, and less frequently of clinical 3 Lewis PJ, Dornan T, Taylor D, Tully MP, Wass V, Ashcroft DM. Preva-
error. Donyai’s study of British hospital prescribing is much more lence, incidence and nature of prescribing errors in hospital inpa-
positive,11 with a one-third reduction in errors, but they did find tients. A systematic review. Drug Saf 2009; 32: 379e89.
new types of errors, such as unintended alterations in dosing 4 Ferner RE. The epidemiology of medication errors: the methodolog-
frequency. The general consensus is that electronic prescribing, ical difficulties. Br J Clin Pharmacol 2009; 67: 614e20.
with an optimal system, is a useful contribution to the reduction of 5 Aronson JK. Medication errors: definitions and classification. Br J Clin
error and the enhancement of patient safety; it is not a total solution Pharmacol 2009; 67: 599e604.
but complements the role of the clinical pharmacist. 6 Aronson JK. Medication errors: what they are, how they happen, and
how to avoid them. QJM 2009; 102: 513e21.
Conclusion 7 Dean B, Schachter M, Vincent C, Barber N. Causes of prescribing errors
in hospital inpatients: a prospective study. Lancet 2002; 359: 1373e8.
No activity can be totally error-free. However, it is possible to
8 Tully MP, Ashcroft DM, Dornan T, Lewis PJ, Taylor D, Wass V. The
define the likely sources of error and to find ways of minimizing
causes and factors associated with prescribing errors in hospital
their occurrence, or at least their impact. Much more can be done
inpatients. A systematic review. Drug Saf 2009; 32: 819e36.
to reduce the incidence of prescribing errors, because virtually all
9 McDowell SE, Ferner HS, Ferner RE. The pathophysiology of medi-
such errors are avoidable. The fact that the impact of prescribing
cation errors: how and where they arise. Br J Clin Pharmacol 2009;
errors is, in the UK at least, greatly mitigated by clinical phar-
67: 605e13.
macy does not justify complacency among prescribers. A
10 Nanji KC, Rothschild JM, Salzberg C, et al. Errors associated with
outpatient computerized prescribing systems. J Am Med Inform Assoc
2011; 18: 767e73.
REFERENCES 11 Donyai P, O’Grady K, Jacklin A, Barber N, Dean Franklin B. The effects
1 Schachter M. The epidemiology of medication errors: how many, how of electronic prescribing on the quality of prescribing. Br J Clin
serious? Br J Clin Pharmacol 2009; 67: 621e3. Pharmacol 2007; 65: 230e7.

MEDICINE 40:7 396 Ó 2012 Elsevier Ltd. All rights reserved.