Tuesday, June 14, 2011

Medical Assistants and Medication Errors

We want to remind all practicing medical assistants that medication errors refer to errors in the processes of ordering, transcribing, dispensing, administering, or monitoring medications, irrespective of the outcome (i.e., injury to the patient). 

One example is an order written for amoxicillin without a route of administration. Other medication errors have a greater potential for patient harm and so are often designated as "serious medication errors" or "potential ADEs"—e.g., an order for amoxicillin in a patient with past anaphylaxis to penicillin.

We also want to remind medical assistants who call in prescription orders to a pharmacy, or approve prescription refills for a patient to do this ONLY upon approval from the doctor. Only call in orders that are logged in the patient's medical chart. Any prescriptions or refill orders completed and called in to the pharmacy should then also be annotated, dated and initialed by the medical assistant who made the call (you!).

  • Always legibly identify yourself by signature, or initials

  • All entries in the medical record must be signed by the author. Federal law mandates that only the author can sign his/her entries in medical records.

  • Abbreviation to Avoid Intended Meaning Misinterpretation Correction
    D/C discharge discontinue Premature discontinuation of medication (intended to mean discharge) especially when followed by a list of discharge medications. Use "discharge" and "discontinue"
    MgSO4 Magnesium sulfate Morphine sulfate
    MSO4 Morphine sulfate Magnesium sulfate
    MTX Methotrexate Mitoxantrone
    ZnSO4 Zinc sulfate Morphine sulfate
    q.d. or QD every day Mistaken as q.i.d. especially if the period after the "q" or the tail of the "q" is misunderstood as an "I". Use "daily" or "every day" If abbreviation is used, capitalize and avoid use of periods.
    q.o.d. or QOD every other day Misinterpreted as "qd"(daily) or "qid" (four times daily) if the "o" is poorly written Use "every other day". If abbreviation is used, capitalize and avoid use of periods.
    U or u units Read as zero (0) or a four (4) causing a 10-fold overdose or greater (4U seen as "40" or 4u seen as "44"). Unit has no acceptable abbreviations. Use "unit".
    IU international units Misread as IV (intravenous) Use "units"
    TIW three times a week Mistaken as "three times a day" Spell out "three times a week"

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