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Council Identifies and Makes Recommendations to Improve Error-prone Aspects of Prescription Writing September 4, 1996 — At its July meeting, the National Coordinating Council for Medication Error Reporting and Prevention, which is devoted to reducing medication errors in health care delivery, has identified a set of simple recommendations that can dramatically reduce the potential for harmful medication errors in medication orders and prescriptions. The recommendations are aimed at safer prescription writing and are an important first step to ensuring the five rights: the right drug in the right dose by the right route to the right patient at the right time. The Council found a consistent prevalence of several problems as it reviewed reports received through the USP Medication Errors Reporting Program. The problems—illegible handwriting, the absence/presence of leading/trailing zeroes, misinterpreted abbreviations, and incomplete medication orders—accounted for approximately 15 percent of medication error reports received by the program. Illegible handwriting on prescriptions and medication orders is the most widely recognized cause of medication errors. Illegibility often leads to misinterpretation by the "reader," which includes the nurse, pharmacist, and/or technical support staff. If the drug name, strength, dosage form, quantity, and/or directions for use are unclear, the ambiguity can result in a patient receiving the wrong drug, the wrong strength, the wrong dosage form, and even the wrong directions for use. Illegibility enables the reader to "misinterpret" what he or she sees, usually with a bias toward drug names with which he or she is familiar. For example, a newly marketed drug that is written illegibly can be misread more easily than one that has been on the market for some time. The Council intends to promote these recommendations broadly to encourage their implementation. The recommendations also will be sent to state medical and pharmacist associations, health professions schools, and other national professional associations representing prescribing health care practitioners (such as nurse practitioners, optometrists, and osteopaths), managed care organizations, and third-party payers. The Council also suggests that the recommendations be considered when developing education and orientation programs for staff in hospitals and long-term care facilities. Council Recommendation   © 1998–2008 National Coordinating Council for Medication Error Reporting and Prevention. All Rights Reserved. *Permission is hereby granted to reproduce information contained herein provided that such reproduction shall not modify the text and shall include the copyright notice appearing on the pages from which it was copied.