COMMUNITY PRACTICE

Washington board joins in offering med error remedies

A symbolic regulation in Washington State requiring that all prescriptions be legible has led to some concrete recommendations on ways the state can reduce medication errors.

Working with the state health department and the state medical and nursing boards, the Washington board of pharmacy helped prepare a medication-error reduction report to be presented to the legislature later this month. In addition, about 2,000 individuals were contacted to provide input, and both large and small hospitals were asked how they deal with medication errors. The report was mandated by legislation adopted last year that requires all prescriptions to be legible but that lacks any penalties for noncompliance by prescribers.

One of the top goals set by the group is elimination of all handwritten prescriptions by 2005, which would require legislation, said Donald Williams, executive director of the pharmacy board. In order to end the long reign of the error-prone paper Rx, the task force is touting the use of handheld electronic prescribing systems. He noted that while there were very few e-Rx systems in 1999, by last year upwards of 20 companies had sought pharmacy board approval.

Look-alike and sound-alike drug names are continuing sources of medication errors, so the Washington groups suggested asking federal agencies to improve drug packaging and labeling and to eliminate confusing names. "One of the areas we identified was the fact that packages all look the same when they all come from the same company, and that makes them easier to mix up on the pharmacy shelf," Williams added.

In addition to calling for more patient education about medications, the recommendations include a provision for putting the prescribed drug's indication on the label. If such a move is mandated, it may run into flak from the state medical society, said Williams. He added that the physician group does support putting the indication on the label, but only if it's not required.

"We hope this is not going to become medicine against pharmacy," Williams said. "The state medical association has been supporting it for three years, but we've done three different studies that have not shown any increase in the incidence of [physicians voluntarily] putting that information on prescriptions. We think the drug indication is an important factor to assist patients, especially the elderly. For example, in 1999 we had something like 25 complaints related to mix-ups between Prozac and Prilosec, which have very different indications. All you have to do is write 'for ulcer' on a Prilosec prescription."

Other suggestions headed to the legislature include writing the age on an Rx when the patient is 14 years old or younger. Voluntary medication-error reporting that follows the federal lead was also touted. And hospitals are being encouraged to adopt proven medication safety practices, including adoption of automated drug-ordering systems.

"This is a major project, and we want to sensitize people to medication errors," Williams said. "By virtue of the Institute of Medicine report, this is the time to focus on making some changes in the whole process. The difficulty is that the medication use system has evolved over the past two centuries, but it isn't really a system. It needs to be systematized. That's what we're going to try to do."

Carol Ukens

 

Carol Ukens. Washington board joins in offering error remedies. Drug Topics 2001;1:25.