A 19-year-old man is admitted with delusions, hallucinations, and disorganized behavior. He is diagnosed with schizophrenia, and the physician writes an order to begin aripiprazole "2.0" mg. The patient mistakenly receives 20 mg aripiprazole instead of 2 mg. This order is overlooked during the pharmacy review process, and the nurse fails to question it before administering aripiprazole to the patient. Which of the following is the most effective intervention to reduce this type of error?

Question

A 19-year-old man is admitted with delusions, hallucinations, and disorganized behavior.  He is diagnosed with schizophrenia, and the physician writes an order to begin aripiprazole "2.0" mg.  The patient mistakenly receives 20 mg aripiprazole instead of 2 mg.  This order is overlooked during the pharmacy review process, and the nurse fails to question it before administering aripiprazole to the patient.  Which of the following is the most effective intervention to reduce this type of error?

Quizplus · Accepted Answer

Illegible orders and transcribing errors are preventable causes of medication errors. In this case, the medication error could be due to an unclear decimal point or a transcription error. Although the increased use of computerized physician order entry systems with drop-down menus for drug, dose, route, and frequency has reduced the incidence of these errors, the systems are not universally available. Physicians must write or enter orders clearly and specifically avoid using trailing zeros to prevent errors in dosage. Studies show that educational interventions to reduce the use of certain abbreviations (eg, QD, μg) and avoid trailing zeros lead to a significant decrease in transcription errors. (Choice A) Confirming the dosage with the patient may be helpful. However, it is an inadequate double-check due to many patients being unaware of their medication dosage or in a mental state (due to a psychiatric or medical condition) that may prevent them from thinking clearly about it. (Choice C) Because a particular medication may be available in different dosages, computerized checks with automated alerts may not consistently identify a higher dosage as an error. Computerized systems are helpful in eliminating illegible orders; identifying patients at high risk for an adverse event; and alerting physicians to medication allergies, drug interactions, and dosage limits. (Choice D) Eliminating trailing zeros entirely is a better option than reminding physicians to be careful placing decimal points. (Choices E and F) Hiring additional nursing and pharmacy staff to perform double-checks on each medication order would not be cost-effective and would not consistently detect handwritten notation errors, as individuals reviewing the orders may influence each other's opinion. Educational objective: Avoiding the use of unsafe abbreviations and trailing zeros in medication orders can help reduce the incidence of medication errors. __________ References: Impact of prescriber's handwriting style and nurse's duty duration on the prevalence of transcription errors in public hospitals. (http://www.ncbi.nlm.nih.gov/pubmed/23228072) Educational interventions to reduce use of unsafe abbreviations. (http://www.ncbi.nlm.nih.gov/pubmed/17519459) Technology utilization to prevent medication errors. (http://www.ncbi.nlm.nih.gov/pubmed/20210714)

A 19-Year-Old Man Is Admitted with Delusions, Hallucinations, and Disorganized