Table 2. Factors associated with medication errors pertaining to outpatient settings of dermatology and systems recommendations for error reduction

Factors Associated with Medication Errors Pertaining to Outpatient Settings of Dermatology	Systems Recommendations for Reducing Medical Errors
Prescribing Errors
Illegible handwriting	· Designate area for order writing and dictation, where prescriber can be seated and free from distractions · Optimize working conditions (e.g., work hours, lighting) · Speak to nurse, pharmacist or patient about prescriptions, especially for patients with multiple diagnoses and prescriptions · Use prescriber self-inking name stamp · Use CPOE
Incomplete orders or orders to “continue” or “resume” or use medications “as directed”	· Do not give orders to “continue”, “resume” or use medications “as directed”—always prescribe specific medications · Staff need to clarify incomplete orders, even during stressful situations · Use CPOE to select complete and specific orders
Inadequate or incorrect patient identifying information	· Use at least two identifiers · All staff in medication use process should continually verify patient identity · Use pre-printed patient stickers · Use CPOE (select patient from a schedule of patients seen that day; enhance font of patient’s name on screen; alerts on similar patient names) · Educate patients on the need to identify themselves (e.g., spell their names, give their birth dates) and their treatments
Inadequate or incorrect knowledge or application of knowledge regarding drug therapy	· Utilize up to date, complete drug references and clinical practice guidelines (e.g., computers, palm pilots) at point of prescribing · Use CPOE with clinical decision support, alerts and reminders
Inadequate or incorrect knowledge or use of knowledge regarding patient factors which affect drug therapy (e.g., contraindications, allergies, drug-drug interactions)	· Conduct complete and accurate medication (including over-the-counter and complementary and alternative medications) and allergy reconciliation at beginning and end of every clinical visit · Utilize up to date, complete drug references and clinical practice guidelines at point of prescribing · Use CPOE with clinical decision support, alerts and reminders · Educate patients and encourage questions
Use of incorrect or misinterpretation of abbreviations, symbols, drug names/abbreviations/stems and dosage	· Maintain list and awareness of common error-prone abbreviations, dose expressions, symbols, drug abbreviations and stems (Table 3) · Adhere to recommended “Do Not Use” lists (e.g., JCAHO [Table 3], institution-specific) · Use CPOE with alerts · Give spoken orders (including telephone orders) only when necessary and insist on read back of order · Educate patients and encourage questions
Use of incorrect or misinterpretation of sound alike or look alike drug names	· Maintain list and awareness of common sound- or look-alike drug names in dermatology (Table 4) · Use CPOE with alerts · Use tall-man letters (e.g., hydrOXYzine vs. hydrALAZINE) · Clearly specify dosage form and strength, and directions for use · Write both generic and brand names · Write drug indication · Educate patients and encourage questions · Give spoken orders (including telephone orders) only when necessary— give drug indication and insist on read back of order
Dosage miscalculation	· Use unit doses, pre-established dose ranges or tables · Incorporate a calculator into CPOE · Require independent checks of calculations (require both calculated dosage and dosage equation to appear on orders to facilitate independent checks)
Dispensing Errors
Dispensing incorrect medication, dosage strength or form	· Use up to date drug references · Use pharmacy computer software which gives automatic alerts and allows a drug use review by pharmacist · Use unit dose dispensing · Use self checking and independent double checks before dispensing · Optimize working conditions (e.g., work hours, lighting) · Counsel patients on dispensed medication
Failure to screen for duplicate prescriptions, allergies, out-of-range doses for patient age or weight, interactions and contraindications	· Use up to date drug references · Use pharmacy computer software which gives automatic alerts and allows a drug use review by pharmacist · Counsel patients on dispensed medication
Look alike drug packaging and labeling	· Store in separate and clearly labeled areas · Order from different manufacturers · Use tall-man letters or other packaging differentiations (e.g., alert stickers, color) · Use barcodes · Counsel patients on dispensed medication
Administration Errors
Inadequate or incorrect patient identifying information	· Use at least two identifiers · All staff in medication use process should continually verify patient identity · Use name bracelets · Use registration cards listing name, record number, birth date for routine clinic patients (with photos), instead of solely relying on a spoken response to the patient’s name · Use interdisciplinary and independent double checks
Inadequate or incorrect knowledge regarding patient factors which affect drug therapy (e.g., age, height, weight, current medications, allergies, diagnoses, laboratory and diagnostic test results, pregnancy and lactation status, vital signs, cultural influences, ability to read instructions and purchase medications)	· Collect all patient information which may affect drug therapy completely and accurately before drug administration · Optimize work conditions (e.g., work hours, adequate staffing, lighting)
Dose omission or duplicate drug administration	· Immediately record drug administration in chart or computerized system (in a designated space) after a medication dose has been given · Use interdisciplinary, independent and automated double checks
Look alike drug packaging and labeling	· Store in separate and clearly labeled areas · Order from different manufacturers · Use all man letters or other packaging differentiations (e.g., alert stickers, color) · Label to the point of administration · Do not list sequentially on computer screens and order forms · Use interdisciplinary, independent and automated double checks · Double check with patient before medication administration and investigate if discrepancies emerge
Staff or patient unfamiliarity with drugs administered	· Provide staff education and competency training · Provide staff with immediate access to up to date drug information or automatic notifications at the point of administration · Educate patients on medication’s brand/generic name, purpose, appearance, administration schedule and method, potential side effects and course of action when experienced, potential drug or food interactions · Use plain language, speak slowly, limit amount of information given to patient and repeat; encourage patient to repeat back and demonstrate learned drug administration techniques; provide patient with simple written instructions, print outs pictures/diagrams, and additional sources of objective, high-quality information

CPOE: Computerized Prescriber Order Entry

JCAHO: Joint Commission on the Accreditation of Healthcare Organizations

Adapted from Kohn et al. [1], Aspden et al. [2], Cohen [8], Lesar et al. [29], Gupta et al. [30], Meyer [31], Daly et al. [32], and Grills and Burge [33].