NTA Level 4 • Semester 1 • PST04101

Prescription Errors

Dispensing • Source Session/Topic 6

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Session 6: Prescription Errors

Total Session Time: 120 minutes + 1 hour assignment

Prerequisites

• None

Learning Tasks

By the end of this session students are expected to be able to:

• Define prescription error

• List common prescription errors

• Identify common prescriptions errors

Resources Needed:

• Flip charts, marker pens, and masking tape

• Black/white board chalk, and whiteboard markers

• Worksheet 6.1: Prescription Errors

SESSION OVERVIEW

SESSION CONTENTS

STEP 1: Presentation of Session Title and Learning Tasks (5 minutes)

READ or ASK students to read the learning Tasks and clarify

ASK students if they have any questions before continuing.

STEP 2: Definition of Prescription Errors (10 minutes)

|Activity: Brainstorming (5 minutes) |

| |

|Ask students to brainstorm on the following question: |

| |

|What is a prescription error? |

| |

|ALLOW few students to respond |

| |

|WRITE their responses on the flip chart/ board |

| |

|CLARIFY and SUMMARISE by using the content below |

• Prescription errors encompass those related to the act of writing a

prescription

• Prescribing faults encompass irrational prescribing, inappropriate

prescribing, under prescribing, overprescribing, and ineffective

prescribing

o These faults arise from erroneous medical judgement or decisions

concerning treatment or treatment monitoring

STEP 3: Common Prescription Errors (30 minutes)

|Activity: Buzzing (5 minutes) |

| |

|ASK students to pair up and buzz on the following question for 5 |

|minutes |

| |

|What are the common Prescription Errors? |

| |

|ALLOW few pairs to respond and let other pairs to add on points not |

|mentioned |

| |

|WRITE their response on the flip chart/board |

| |

|CLARIFY and SUMMARIZE by using the content below |

The following are the common prescription errors:

• Omission error

• Wrong dose error

• Extra dose error

• Wrong dose form error

• Wrong time error

• Wrong drug

• Wrong route of administration

• Wrong frequency

• Wrong duration of treatment,

• Poor legibility of handwriting (unknown abbreviations)

• Unintended omissions

• Incomplete Medical Prescription (If any component of a Medical

Prescription is not filled)

STEP 4: Identification of Common Prescription Errors (60 minutes)

|Activity: Small Group Discussion ( 40 minutes) |

| |

|DIVIDE students into small manageable groups |

| |

|ASK students to discuss on the following question |

| |

|What are the errors in the provided prescriptions? |

|[pic]REFER students to Worksheet 6.1 Prescription Errors SERIAL No. |

|001-005 |

| |

|ALLOW students to discuss for 15 minutes |

| |

|ALLOW few groups to present and the rest to add points not mentioned |

| |

|CLARIFY and SUMMARIZE by using the contents below |

Students should be able to identify the following Prescription errors:

• Serial No.001

o Incomplete name of the patient

o No signature

o Duration of medicine missing (erythromycin)

o Wrong frequency of paracetamol

• Serial No. 002

o Name of the institution is not known

o Strength of paracetamol is not known

o Prescriber’s name is missing

• Serial No.003

o Age of the patient is missing

o Polypharmacy- no need to dispense two analgesics (paracetamol and

aspirin)

o Atenolol strength is not 5.0 but there is 50 mg or 100 mg, mistake in

writing

• Serial No.004

o Sex is not indicated (gender)

o Doxycycline and magnesium should not be given together, they interact

each other

o Magnesium strength is not shown

• Serial No.005

o No date

o Tetracycline Bd ×2/52

o Wrong medicine for the indication i.e. amoebiasis is treated with

Nitronidazole (Metronidazole, Ttinidazole, Secnidazole)

o Medicine does not tell the dosage form i.e. is it tablet, ointment

capsule.

o Drug name should be generic and not trade name (Tulizamol should be

written as Paracetamol)

STEP 5: Key Points (5 minutes)

• Medication errors are common in general practice and in hospitals.

• Both errors in the act of writing (prescription errors) and prescribing

faults due to erroneous medical decisions can result in harm to patients

• Any step in the prescribing process can generate errors

• Inadequate knowledge or competence and incomplete information about

clinical characteristics and previous treatment of individual patients

can result in prescribing faults, including the use of potentially

inappropriate medications

STEP 5: Evaluation (5 minutes)

• What are prescription errors?

• What are the common prescription errors?

References

Cornish, P.L, Knowles, S.R, Marchesano, R, Tam, V, Shadowitz, S, Juurlink,

DN, Etchells, E, E. (2005). Arch Intern Med: Unintended medication

discrepancies at the time of hospital admission. 2005;165:424–9.

Dean, B., Schachter, M., Vincent, C, Barber, N (202). Lancet: Causes of

prescribing errors in hospital inpatients: a prospective study.

359:1373–8.

Dean, B., Vincent, C, Schachter, M., Barber, N (2005). Drug Saf:The

incidence of prescribing errors in hospital inpatients: an overview of

the research methods.. 28:891–900.

Knudsen, P., Herborg, H., Mortensen, A,R., Knudsen, M., Hellebek, A

.(2007). Qual Saf Health Care:Preventing medication errors in

community pharmacy: root-cause analysis of transcription errors.

16:285–290.

Lesar, T.S., Briceland, L., Stein, D, S. (1997). JAMA:Factors related to

errors in medication prescribing.. 277:312–317.

Spinewine, A., Schmader, K,E., Barber, N., Hughes, C., Lapane, K,L., Swine,

C., Hanlon, J,T. (2007). Lancet: Appropriate prescribing in elderly

people: how well can it be measured and optimised? 370:173–184.

Tam, V,C., Knowles, S,R., Cornish, P,L., Fine., Marchesano, R., Etchells,

E,E. (2005). CMAJ: Frequency, type and clinical importance of

medication history errors at admission to hospital: a systematic

review..173:510–5.

Velo, G, P., & Minuz, P. (2009). British Journal of Clinical Pharmacology:

Medication errors: prescribing faults and prescription errors. 67:6

|[pic] |Worksheet 6 .1: Prescription Errors Serial No. 001-005 |

|Serial Na. 002 |

|Name: |Mariam Juma |

|Gender: |Me |

|Age: |20Yrs |

|Weight: |60kg |

|Rx |Amoxicillin 500mg tds |

| |7/7 |

| |Paracetamol Tabs 100g |

| |tds 3/7 |

|qualifica|CO |

|tion | |

|Signature|[pic]10/07/2015 |

|Serial Na. 001 |

|KIHESA HEALTH CENTER |

|P.O. Box 558 |

|IRINGA |

|Name: |John |

|Gender: |Me |

|Age: |20Yrs |

|Weight: |60kg |

|Rx |Erythromycin tabs 500mg |

| |q.i.d |

| |Paracetamol Tabs 1g Bd |

| |3/7 |

|Prescribe|Masige Kahwa Malimbo |

|r’s name |MO |

|qualifica|11/09/2015 |

|tion | |

|Serial Na. 003 |

|KIHESA HEALTH CENTER |

|P.O. Box 558 |

|IRINGA |

|Name: |Salum Hussein |

|Gender: |Me |

|Weight: |60kg |

|Rx |Asprin 300mg tds 7/7 |

| |Paracetamol Tabs 1g tds |

| |3/7 |

| |Atenolol 5.0mg Od 1/30 |

|Prescribe|Masige Kahwa Malimbo |

|r’s name |MO |

|qualifica| |

|tion | |

|Signature|[pic]20/04/2015 |

|Serial Na. 004 |

|KIHESA HEALTH CENTER |

|P.O. Box 558 |

|IRINGA |

|Name: |Kalunde Athuman |

|Age: |20Yrs |

|Weight: |60kg |

|Rx |Doxycycline100 Bd 7/7 |

| |Magnisium Tricylicate |

| |tds 3/7 |

|Prescribe|Ulimbo Ole |

|r’s name |MO |

|qualifica| |

|tion | |

|Signature|[pic]17/02/2015 |

| | |

|Serial Na. 005 |

| |

|KIHESA HEALTH CENTER |

|P.O. Box 558 |

|IRINGA |

|Name: |John |

|Gender: |Me |

|Age: |20Yrs |

|Weight: |60kg |

|Dx |Amoeba |

|Rx |Tetracyclin Bd 2/52 |

| |Tulizamol Tabs 1g tds |

| |3/7 |

|Prescribe|Masige Kahwa Malimbo |

|r’s name |MO |

|qualifica| |

|tion | |

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