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
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.