1. Bad Writing, Wrong Medication
Spotlight Case
Bad Writing, Wrong Medication

2. Source and Credits
This presentation is based on the April 2010 AHRQ WebM&M Spotlight Case
See the full article at
CME credit is available
Commentary by: Beth Devine, PharmD, MBA, PhD University of Washington
Editor, AHRQ WebM&M: Robert Wachter, MD
Spotlight Editor: Brian Alldredge, PharmD
Managing Editor: Erin Hartman, MS

3. Objectives
At the conclusion of this educational activity, participants should be able to:
Differentiate between a medication error and an adverse drug event
Appreciate the system complexities involved in medication errors that occur in ambulatory settings
List at least 3–5 elements that comprise a framework for conducting a root cause analysis of a medication error

4. Case: Bad Writing, Wrong Medication (1)
A 73-year-old man with a longstanding cardiac arrhythmia came to the ambulatory clinic for a routine follow-up visit. After evaluation, he received a handwritten prescription for Rythmol (propafenone) 150 mg, which had been his usual antiarrhythmic medication for the past 3 years. The patient delivered the prescription to the clinic pharmacy and it was filled.

5. Case: Bad Writing, Wrong Medication (2)
Shortly after starting to take the medication, the man began to feel “very, very bad,” with nausea, sweating, and an irregular heartbeat. These symptoms persisted for 2 weeks and the patient called his physician to schedule another appointment. The patient brought the medication to his physician, stating that the Rythmol tablets looked different from their usual appearance.

6. Definitions of Medication Errors and Adverse Drug Events
“any preventable event that may cause or lead to inappropriate medication use or patient harm while the medication is in the control of the health care professional, patient, or consumer”
Adverse drug event (ADE)
“an injury resulting from a medical intervention related to a drug”
National Coordinating Council for Medication Error and Reporting and Prevention. Available at
Bates DW, Boyle DL, Vander Vliet MB, Schneider J, Leape L. Relationship between medication errors and adverse drug events. J Gen Intern Med. 1995;10:
See Notes for references.

7. Relationship Between Medication Errors and ADEs
Bates DW, Boyle DL, Vander Vliet MB, Schneider J, Leape L. Relationship between medication errors and adverse drug events. J Gen Intern Med. 1995;10:
See Notes for reference.

8. Epidemiology
Estimated that 21% of handwritten prescriptions contain at least one prescription-writing error
Between 2%–24% of prescriptions are dispensed erroneously, and 1.5%–4% of these errors could cause harm
Up to 38% of ADEs in the ambulatory setting are preventable
Shaughnessey AF, Nickel RO. Prescription-writing patterns and errors in a family medicine residency program. J Fam Pract. 1989;29:
Flynn EA, Barker KN. Research on errors in dispensing and medication administration. In: Cohen MR, ed. Medication Errors, 2nd ed. Washington, DC: American Pharmacists Association; 2007:20. ISBN:
Rolland P. Occurrence of dispensing errors and efforts to reduce medication errors at the Central Arkansas Veteran’s Healthcare System. Drug Saf. 2004;27:
Honigman B, Lee J, Rothschild J, et al. Using computerized data to identify adverse drug events in outpatients. J Am Med Inform Assoc. 2001;8:
Gandhi TK, Weingart SN, Borus J, et al. Adverse drug events in ambulatory care. N Engl J Med. 2003;348:
Gurwitz JH, Field TS, Harrold LR, et al. Incidence and preventability of adverse drug events among older persons in the ambulatory setting. JAMA. 2003;289:
Field TS, Gilman BH, Subramanian S, Fuller JC, Bates DW, Gurwitz JH. The costs associated with adverse drug events among older adults in the ambulatory setting. Med Care. 2005;43:
See Notes for references.

9. Case: Bad Writing, Wrong Medication (3)
Based upon the altered appearance of the tablets, both the patient and the physician suspected that this might not be the correct drug. Upon investigation, the physician identified the medication as Synthroid (levothyroxine) 150 mcg, not the intended Rythmol (propafenone) 150 mg. When the physician spoke with the pharmacist who filled the prescription, it became apparent that a medication dispensing error had occurred due to unclear handwriting on the original prescription.

10. Case: Bad Writing, Wrong Medication (4)
The physician felt that the patient’s symptoms of nausea, sweating, and irregular heartbeat were related to both inadvertent, abrupt discontinuation of Rythmol and the unnecessary use of Synthroid at a relatively high initial dosage. Synthroid was immediately discontinued and the patient restarted Rythmol as originally prescribed.

11. Systems-Based Approach to Error
Recognizes that errors stem from weaknesses in individual components of the health care system
Weaknesses are best addressed through multidisciplinary engagement
Identifying root causes of error is more important than determining who was involved
Cohen MR. Causes of medication errors. In: Cohen MR, ed. Medication Errors, 2nd ed. Washington, DC: American Pharmacists Association; 2007: ISBN:
See Notes for reference.

12. Framework for Root Cause Analysis of Medication Errors
Access to patient-specific information
Access to drug information
Adequate communication
Proper labeling, packaging, and nomenclature
Drug standardization, storage, and monitoring
Cohen MR. Causes of medication errors. In: Cohen MR, ed. Medication Errors, 2nd ed. Washington, DC: American Pharmacists Association; 2007: ISBN:
See Notes for reference.

13. Framework for Root Cause Analysis of Medication Errors (cont.)
Medication delivery device use and monitoring
Sufficient environmental support
Staff competency and education
Patient education
Quality improvement and risk management programs
Cohen MR. Causes of medication errors. In: Cohen MR, ed. Medication Errors, 2nd ed. Washington, DC: American Pharmacists Association; 2007: ISBN:
See Notes for reference.

14. Information Technology
Electronic medical records (EMR) can provide patient-specific data when it is needed
Barcoding technologies can be used to reduce dispensing errors
Computerized provider order entry (CPOE) can reduce medication errors — e.g., those related to illegibility, abbreviations, and missing information
Aspden P, Wolcott J, Bootman JL, Cronenwett LR, eds. Preventing Medication Errors: Quality Chasm Series. Washington, DC: National Academies Press; ISBN:
Bates DW, Leape LL, Cullen DJ, et al. Effect of computerized physician order entry and a team intervention on prevention of serious medication errors. JAMA. 1998;280:
Devine EB, Hansen RN, Wilson-Norton JL, et al. The impact of computerized provider order entry on medication errors in a multispecialty group practice. J Am Med Inform Assoc. 2010;17:
See Notes for references.

15. Office-Based Physician Practices
Approximately 17% use a “basic” EMR system that includes functionality for prescription ordering
Only 4% use a “fully functional” EMR that also allows for electronic prescription transmittal to a receiving pharmacy computer system
Hsiao CJ, Beatty PC, Hing ES, Woodwell DA, Rechtsteiner EA, Sisk JE. Electronic medical record/electronic health record use by office-based physicians: United States, 2008 and Preliminary National Center for Health Statistics. December Available at
See Notes for reference.

16. Pharmacist Counseling
States are required to establish standards governing patient counseling for prescriptions
Most states require the offer of pharmacist counseling for new prescriptions only
When offered, patients may refuse counseling on new prescriptions
Interchange between pharmacist and patient can provide a final check to prevent medication errors
Vivian JC, Fink JL. OBRA ’90 at Sweet Sixteen: A retrospective review. US Pharmacist 2008;33: Available at
See Notes for reference.

17. In This Case
This medication error was a preventable ADE and caused patient harm
System improvements could reduce this type of error
CPOE would have eliminated prescription illegibility
Pharmacist access to patient-specific information in an EMR might have revealed indication for medication
Patient counseling at point of dispensing might have provided opportunity to catch error
Patient empowerment might have prompted patient to question pharmacist or physician about prescription change

18. Take-Home Points
Medication errors are potential adverse drug events; medication errors that cause harm are preventable adverse drug events
Not all adverse drug events are caused by medication errors (i.e., some are side effects)
Because outpatient ambulatory health care delivery is a fragmented process, estimating medication errors and adverse drug events in this setting is challenging
Even seemingly simple medication errors are multifactorial, involving more than one process and more than one line of responsibility
Refs here

19. Take-Home Points (2)
As with medication errors that occur in acute care environments, serious ambulatory medication errors should also be analyzed from a systems perspective (root cause analysis) by members of an interdisciplinary team
Electronic medical records with computerized provider order entry systems, when implemented correctly, will mitigate certain types of medication errors, thereby improving medication safety