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Think medical records are an accurate source for medication history? Think again.


From the Oct. 8, 1997 Issue

PROBLEM:Because medical records are often recorded, in part, from dictation, there may be errors in them. Case in point: a discharged patient was readmitted, and the admitting physician wrote for "olanzapine 50 mg q HS." The usual dose of olanzapine (Zyprexa®) is only 5-10 mg. The nurse recognized the high dose of the drug and questioned it, but the physician insisted that the patient had been discharged on that dose. The pharmacist who received the order checked a little further and found that the patient had been taking olanzapine 15 mg during his previous admission. In the medical record, the oral discharge summary had been misunderstood by the transcriptionist, who recorded "50 mg" instead of "15 mg." The pharmacist had the order changed, and the patient received the correct dose.

SAFE PRACTICE RECOMMENDATION: This case brings up several points: verbal communications for drug doses should be stated the way pilots state numbers ("15 mg" is "one-five mg"). Had the order been so stated, the error would not have occurred. This method is especially important when stating doses of critical medications such as insulin.

Records of medical dictations must be carefully checked by the practitioner who dictated them, especially drug doses. Practitioners giving dictation should assume that medical records won't always be transcribed correctly. Medical records staff should bold drug names and doses in the transcription as a signal to practitioners to verify the name and dose. Practitioners, then, must carefully read the transcribed dictation for accuracy. It is the responsibility of both the practitioner who dictates the records and the medical records staff to assure accuracy, but the transcriptionists often must contend with unfamiliar drug names and, sometimes, poor pronunciation by practitioners.

Finally, a great problem exists when admission orders are written by prescribers who are totally unfamiliar with the medication and/or the patient. Since pharmacists are almost always just a phone call away, they should be consulted before the chart is returned for processing.

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