Bad "marks" for order communication
From the September 18, 2002 issue
PROBLEM: Marks on order forms - whether stray or well
intentioned - can lead to errors. Several reports submitted
this year demonstrate this problem. In one case, a 70-year old
patient received a ten-fold overdose of DILAUDID (hydromorphone)
after a pharmacist misinterpreted a circle with the prescriber's
initials in it as a zero. A physician prescribed PCA using hydromorphone
2 mg in 250 mL of sodium chloride 0.9% injection, creating a
concentration of 8 mcg/mL. While writing the order on a preprinted
form, the fellow mistakenly entered the 8 mcg/mL concentration
on the wrong line. He quickly recognized his mistake, scribbled
over the erroneous 8 mg entry, and wrote the correct dose of
2 mg/250 mL. He then initialed the change and circled it.
Unfortunately, the pharmacist mistook the circled initials
as a zero and dispensed "20" mg of hydromorphone
in 250 mL normal saline, yielding a concentration of 80 mcg/mL.
The bag was labeled as "20 mg/250 mL NS," but the
concentration was mislabeled as "8 mcg/mL." Before
administration, two nurses checked the bag using the original
order, but they only verified the labeled concentration. So,
the error was not noticed because the concentrations on the
order form and the mislabeled bag were the same. Later, a
night nurse found the error while checking the bag against
the original order. The patient exhibited no ill effects.
In another case, a handwritten order for the anticholinergic
LEVBID (hyoscyamine extended release) was misread as
the antiarthritic ENBREL (etanercept) because the "L"
in Levbid was obscured by a unit secretary's checkmark. In
this case, an error was averted because Enbrel is administered
subcutaneously and the Levbid was prescribed orally. We've
also seen initials or the letters "M," "K,"
and "O" at the beginning of each order to indicate
that it's been transcribed onto the MAR (medication
administration record) or Kardex, or has been Ordered.
Such markings can lead to misinterpretation. For example,
in our October 22, 1997 issue, we wrote about an error where
ACCUPRIL (quinapril) looked more like MONOPRIL
(fosinopril) because a unit secretary placed an "M"
in front of the order to note that it had been transcribed
onto the MAR. In another case, "40 mg Tylenol Infants
Drops" looked like 140 mg because the order was preceded
by a checkmark.
SAFE PRACTICE RECOMMENDATION: Errors related to order
transcription can be reduced with computerized prescriber
order entry systems. Until such systems are in place, however,
nurses and unit secretaries should be warned that initials,
letters, checkmarks, and other incidental marks used during
transcription of handwritten orders can obscure or change
how a medication order appears. Such marks are especially
error-prone if NCR (no carbon required) order copies are sent
or faxed to the pharmacy. If applicable, order copies should
be sent to the pharmacy before transcription notation is documented
on the forms. To be safe, notations to signal that order transcription
is complete or verified should be made at the bottom of orders
to avoid interference with individual orders. Use of a red
pen could help differentiate marks on the original order copy.
If checkmarks or notations must be used for large order sets,
order forms should be designed with a separate column or box
in which to place the check mark or notation to communicate
that an order has been transcribed. Otherwise, alternative
methods of communicating particulars about order transcription
should be established to avoid unnecessary marks or notes
on the order form itself. Similarly, prescribers should avoid
using numbers to organize their handwritten orders, and should
always list the dose of a medication after its name, not before
It's also important to ensure that all corrections of erroneous
entries in the medical record follow a process whereby: 1)
the error is crossed out with a single line; and 2) the initials
of the person making the correction are listed in the upper
right-hand corner, directly next to the erroneous entry (not
the corrected entry). It's unnecessary, and risky, to place
a circle around the initials.