The age-old problem of doctors' scrawling illegibly while writing prescriptions is concerning Canadian health professionals.
At best, pharmacists may be frustrated trying to decipher exactly what the doctor ordered; at worst, it can lead to serious medication errors that can harm or even kill patients.
A whole gamut of solutions is being adopted across the country, from awareness and education to help doctors write better, to electronic prescribing systems that are the wave of the future.
Focus on Penmanship
The Winnipeg Regional Health Authority (WRHA) recently launched an education campaign consisting of a series of eight posters highlighting key expectations from the region's policy on writing medication orders.
The campaign was prompted by results of an audit showing that 1 per cent of medication orders written in the region's hospitals were completely illegible.
"We worry that the ones that are a bit questionable that we don't clarify are really the ones that are going to be more dangerous," said Lora Jaye Gray, WRHA's Medication Safety Coordinator. For example, what looks like "5 mg" may in fact be ".5 mg" if the decimal point is unclear, leading to a patient receiving ten times the actually prescribed dosage.
Furthermore, about 30 per cent of prescriptions contain a "banned abbreviation" instead of a name or term completely spelled out. "U," for instance, is banned as an abbreviation for "Units" because it can be misread as a zero, a four, or a cc, which stands for cubic centimetre and would lead to a dose being given in volume instead of units.
"We would like to see clear and complete medication orders," said Gray, noting that this standard applies not only to physicians but also to nurses, pharmacists, and other health workers.
Stamping out Confusing Drug Names
Another common source of medication errors is look-alike, sound-alike drug names such as Levoxine and Lanoxin, or Xanex, Xanax, and Zantac. According to Health Canada, confusing drug names account for 10,000 patient injuries annually in the U.S. and 29 per cent of pharmacy dispensing errors. The figures are similar in Canada.
The WRHA campaign is asking doctors not to abbreviate but to write clear and complete generic medication names. Meanwhile, Dr. Greg Kondrak from the University of Alberta, has developed two algorithms that have been combined to create an application to analyze proposed drug names and determine their confusability against the names of existing and other proposed drugs.
Since 2003 the U.S. Food and Drug Administration (FDA) has been using Kondrak's application, called Phonetic and Orthographic Computer Analysis (POCA), to support its Health Products Name Review process. The FDA and Health Canada have an agreement to share POCA, said Myriam Wallet from Health Canada's Therapeutic Products Directorate. She said POCA will likely start testing in October in Canada.
Automation Results Promising
Canada published its first national study on adverse events in acute care hospitals in 2004. The study reported that in 2000, 7.5 per cent (185,000) of 2.5 million adult admissions resulted in an adverse event—an unintended injury or complication resulting in death, disability, or prolonged hospital stay.
Twenty-five per cent of those events were associated with a drug/fluid-related incident. While not all were due to medication errors, the study stated that the incidence of health system error in Canada is comparable with other industrialized countries.
A 1998 U.K. study published in the British Medical Journal found that doctors, even when asked to write neatly, produced writing that is worse than that of other professionals.
And last month a U.S. study published in the Health Services Research journal found that as high as 61 per cent of medication errors in hospitals are caused by illegibly or incorrectly written prescriptions.
With many thousands of patients affected, the situation is indeed serious. Advocates of e-prescribing systems that lets doctors order drugs electronically—called computerized physician order entry (CPOE)—believe the "ultimate solution" lies in automation.
The U.S. study reviewed 12 other U.S. studies that compared hospital medication errors made with computerized prescriptions versus handwritten prescriptions. It found that computer prescribing reduced total prescribing errors by 66 per cent, dosage errors by 43 per cent, and events causing patient harm by 37 per cent.
In Canada, the University Health Network (UHN) in Toronto, one of Canada's largest teaching hospitals, has found similar promising results. Two years ago it implemented a CPOE system along with a companion system that allows nurses to document actual drug administration to patients.
Analysis shows a 42 per cent post-implementation decrease in major ordering and transcription errors, said Lydia Lee, Executive Director of UHN's Shared Information Management Services.
Cancer Care Ontario (CCO) is another success story. Unlike the commercial software used by UHN, CCO's system is developed in-house because chemotherapy has very particular needs, explained Sarah Kramer, Vice-President and Chief Information Office.
For example, it must be able to order a course of drugs over several weeks. Also, some chemotherapy drugs have a total lifetime safe maximum amount, so the system must be able to alert the physician if a prescription order will exceed that maximum.
Moreover, the narrow "therapeutic range" of cancer chemotherapy means giving too much of a drug can risk killing a patient, while giving too little risks not providing the intervention needed. The system needs to be able to do these calculations, Kramer said.
First implemented in 2000, CCO's system is now used in 15 sites and serves nearly 60 per cent of cancer patients across Ontario.
Overcoming Barriers
Canada Health Infoway is a not-for-profit organization that works with public sector partners such as CCO and UHN to implement electronic health record systems across Canada.
Dr. Sarah Muttitt, Infoway's Vice-President of Innovation and Adoption, says evidence is strong that CPOE, especially when combined with computer support for doctors and pharmacists to make clinical decisions, improves the quality and safety of care "particularly in the area of reducing medication errors."
Ten to 15 per cent of Canadian hospitals have the capability right now, she said, but "we need those same capabilities out in the community where 80 per cent or more of clinical care is delivered." She said only about 20 per cent of Canada's community-based physicians' offices are automated, with Alberta being the most progressive of all the jurisdictions.
Muttitt added that Infoway is developing pan-Canadian standards to ensure compatible systems so that doctors' offices, hospitals, and pharmacies can all share information such as drug data and patients' medical histories.
To overcome barriers to automation, Muttitt stressed that "it really means involving your clinicians in the development of systems to ensure they have the right kind of functionality, ease of use, and that their workflow is taken into consideration."
While noting that "the ultimate solutions really are found in changing systems, not through one doctor at a time," Kramer nevertheless applauded the Winnipeg campaign to help improve doctors' penmanship.
Gray agrees it's a big project, adding that Winnipeg is also moving toward the direction of e-prescribing.
"When [e-prescribing systems] become mainstream, I think we will really start to see the benefits for patient care," said Kramer.