Baylor University Medical Center Proceedings April 2017 - 146

Avg Rx/Hr

Number of Rxs

15
13

12
10

10
7

8
6
4
2

9
7

4 4
2 2

2 1

10
7

7
4

4
3

Percent of Rxs with errors

20
15

14
13

12
9

12
10

9
7 7
6

5
0

0:00
1:00
2:00
3:00
4:00
5:00
6:00
7:00
8:00
9:00
10:00
11:00
12:00
13:00
14:00
15:00
16:00
17:00
18:00
19:00
20:00
21:00
22:00
23:00

23
% With an Error 21

Hour Rx was printed

Figure 1. (a) Average number of prescriptions (Rx) written per hour. (b) Percentage of prescription errors per hour.

medication reconciliation (13), reducing pediatric adverse drug
events (14, 15), reducing pediatric prescription errors (16), and
reducing ED prescription errors (6). A dedicated discharge prescription reviewing policy may be prudent; however, implementation could have an impact on ED metrics such as total length
of stay in the ED for those being discharged. Pharmacists could
also conduct in-service training regarding the importance of
electronically correcting prescriptions in lieu of hand-correcting
the already printed version.
This study is not without its limitations. The prescriptions
reviewed spanned a 6-day period and represented a small subset
of physicians. Also, any handwritten prescription corrections
or handwritten prescriptions that may have been distributed
during these 6 days were not included in the analysis. Additionally, the potential for harm or delay of patient receipt was not
assessable. Finally, interobserver variability was not formally
assessed, and classiﬁcation bias cannot be ruled out.
This pilot study can help researchers springboard into more
robust research, including conﬁrmation of error rate with a
larger sample size, design of interventions to help reduce error
rates, improvement of error rates after the educational intervention in this particular academic medical center ED, and further
solidiﬁcation of the positive impact an ED pharmacist can have
on discharge prescription error rates.
1.

146

Food and Drug Administration. Avoiding medication mistakes (updated
8/31/15). Available at http://www.fda.gov/ForConsumers/ConsumerUpdates/ucm048644.htm; accessed November 20, 2015.
Budnitz DS, Pollock DA, Weidenbach KN, Mendelsohn AB, Schroeder
TJ, Annest JL. National surveillance of emergency department visits for
outpatient adverse drug events. JAMA 2006;296(15):1858-1866.
Budnitz DS, Shehab N, Kegler SR, Richards CL. Medication use leading
to emergency department visits for adverse drug events in older adults.
Ann Intern Med 2007;147(11):755-765.
Lifshitz AE, Goldstein LH, Sharist M, Strugo R, Asulin E, Haim SB,
Feigenberg Z, Berkovitch M, Kozer E. Medication prescribing errors in the
prehospital setting and in the ED. Am J Emerg Med 2012;30(5):726-731.

8.
9.
10.

11.

12.

13.

14.

15.

16.

Sard BE, Walsh KE, Doros G, Hannon M, Moschetti W, Bauchner H.
Retrospective evaluation of a computerized physician order entry adaptation to prevent prescribing errors in a pediatric emergency department.
Pediatrics 2008;122(4):782-787.
Cesarz JL, Steﬀenhagen AL, Svenson J, Hamedani AG. Emergency department discharge prescription interventions by emergency medicine
pharmacists. Ann Emerg Med 2013;61(2):209-214.
Terrell KM, Perkins AJ, Dexter PR, Hui SL, Callahan CM, Miller DK.
Computerized decision support to reduce potentially inappropriate prescribing to older emergency department patients: a randomized, controlled
trial. J Am Geriatr Soc 2009;57(8):1388-1394.
Condren M, Studebaker IJ, John BM. Prescribing errors in a pediatric
clinic. Clin Pediatr 2009;49(1):49-53.
Taylor BL, Selbst SM, Shah AEC. Prescription writing errors in the pediatric
emergency department. Pediatr Emerg Care 2005;21(12):822-827.
Acute Care IMSP Safety Alert. "Use as directed" can cause confusion for
both patients and practitioners. Horsham, PA: Institute for Safe Medication
Practices, August 2016. Available at http://www.ismp.org/newsletters/
acutecare/showarticle.aspx?id=1146; accessed January 25, 2017.
Bizovi KE, Beckley BE, McDade MC, Adams AL, Lowe RA, Zechnich
AD, Hedges JR. The eﬀect of computer-assisted prescription writing
on emergency department prescription errors. Acad Emerg Med 2002;
9(11):1168-1175.
Kuo GM, Touchette DR, Marinac JS. Drug errors and related interventions reported by United States clinical pharmacists: the American
College of Clinical Pharmacy Practice-Based Research Network medication error detection, amelioration and prevention study. Pharmacotherapy
2013;33(3):253-265.
Leguelinel-Blache G, Arnaud F, Bouvet S, Dubois F, Castelli C,
Roux-Marson C, Ray V, Sotto A, Kinowski JM. Impact of admission medication reconciliation performed by clinical pharmacists on medication
safety. Eur J Intern Med 2014;25(9):808-814.
Kaushal R, Bates DW, Landrigan C, McKenna KJ, Clapp MD, Federico F,
Goldmann DA. Medication errors and adverse drug events in pediatric
inpatients. JAMA 2001;285(16):2114-2120.
Condren M, Honey BL, Carter SM, Ngo N, Landsaw J, Bryant C,
Gillaspy S. Inﬂuence of a systems-based approach to prescribing errors
in a pediatric resident clinic. Acad Pediatr 2014;14(5):485-490.
Winder MB, Johnson JL, Planas LG, Crosby KM, Gildon BL,
Oberst-Walsh LA. Pharmacist-led educational and error notiﬁcation
interventions on prescribing errors in family medicine clinic. J Am Pharm
Assoc 2015;55(3):238-245.

Baylor University Medical Center Proceedings

Volume 30, Number 2

http://www.ismp.org/newsletters/acutecare/showarticle.aspx?id=1146 http://www.ismp.org/newsletters/acutecare/showarticle.aspx?id=1146 http://www.fda.gov/ForConsumers/Consumer-Updates/ucm048644.htm http://www.fda.gov/ForConsumers/Consumer-Updates/ucm048644.htm

Table of Contents for the Digital Edition of Baylor University Medical Center Proceedings April 2017