BMJ  2004;328:1172-1173 (15 May), doi:10.1136/bmj.328.7449.1172

Commentary

Computer aided prescribing leaves holes in the safety net

R E Ferner, director1

1 West Midlands Centre for Adverse Drug Reaction Reporting, City Hospital, Birmingham B18 7QH r.e.ferner@bham.ac.uk

The first 150 words of the full text of this article appear below.

Patients die from poor prescribing. As with so much else, poor communication is a major culprit. Amoxil (amoxicillin) is misread as Daonil (glibenclamide) because of bad handwriting; 10U is interpreted as 100 [units] because of inappropriate abbreviation; patients are overdosed with a standard release drug when a modified release formulation was intended but not specified.1 The prescribing process is complex, and opportunities for error abound. Patients may be given drugs they are allergic to, or which are contraindicated or have already been prescribed under another name; one drug may interact with another; the dosage, or duration, or formulation, or route may be wrong: in short, anything that can go wrong in prescribing will go wrong.

Computers can help. They reduce medication error rates by as much as 60% simply by ensuring that prescriptions are legible, complete, and in a standard format.2 That is encouraging, but patients still die from the . . . [Full text of this article]


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