Editor’s Note: The SCPIE Companies, in collaboration with the California Medical Association and two other liability insurers, developed these safe medication principles. Although the principles are shown as drafted, supplemental information has been included in this article to customize the content for SCPIE insureds.

Safe medication practices promote patient safety, enhance the results of medication use and reduce liability loss. To achieve these goals, the following principles are offered to assist physicians form effective therapeutic partnerships with their patients. The global intent of these principles is to identify and address actions that have been shown by experience and numerous studies to be associated with the decreased risk of undesired effects.

In an effective therapeutic partnership, the physician’s contribution is to prescribe the appropriate medication and to educate the patient about its use. The patient’s contribution is to take medications according to instructions and to report back to the physician both the positive and negative effects. (Pharmacists and nurses also have an important role in the therapeutic partnership. The focus of these principles, however, is on the relationship between the knowledgeable physician and the informed patient.)

Familiarity with the medications you prescribe helps avoid uncertain results.
Studies have shown that lack of familiarity is a significant factor in prescribing errors. Understand the indications, contraindications, side effects and appropriate dosage of all medications you prescribe, particularly those for pediatric and elderly patients.

A careful inventory of medications and other substances reduces surprise drug interactions.
Ask patients what medications other physicians have prescribed; ask the patient about his or her use of over the- counter preparations, vitamins, herbs, and complementary medicine remedies. Inquire about alcohol and “recreational” drug use. In general, a physician needs to know what the patient takes to “feel better.” Ask patients who do not recall their medications and other preparations to bring all of them to the next office visit. Time spent eliciting an accurate medication history is time saved treating an adverse drug reaction.

Indications on prescriptions prevent dispensing errors.
On prescriptions, write the condition for which the medication is prescribed.

A detailed allergy history limits the risk of treatment failure.
Ask patients about allergies to medications, foods or other substances. Document reported allergies on a brightly colored sticker on the cover of each patient’s chart. (Write “NKDA” to indicate “no known drug allergy.”) Update this information regularly. Be aware of unusual allergic manifestations.

Legibility reduces error.
To ensure legibility, print all prescriptions. Encourage your staff to verify orders as needed.

Clear abbreviations avoid confusion.
Spell out abbreviations for directions:

• Write “daily” instead of “q.d.”
• Write “four times daily” instead of “q.i.d.”
• Write “unit” instead of “u”
• Write “ml” instead of “cc”
• Write “thirty” instead of “30”

Misplaced decimal points lead to dosage errors.
When it comes to zeroes, “always lead, never trail.” When writing dosage amounts on prescriptions, use a leading zero before a decimal point of a fractional number (e.g., 0.5 mg); do not use a trailing zero after whole numbers (e.g., write “5 mg” not “5.0 mg”).

Writing out numbers prevents alterations.
To prevent alterations on prescriptions for controlled substances, write out the amount to be dispensed (e.g., write “thirty” rather than “30”).

Documenting orders and refills tracks appropriate use.
To facilitate documentation and review, use a dedicated medication control record that can be attached to the inside cover of each patient’s chart. Include the indications for the prescription, name of the drug, the dose, amount and directions. Avoid vague and ambiguous medication orders such as “Refill meds.”

Informed patients follow instructions.
Dispense written information about drugs in plain language to advise patients about (a) the name of the drug and what it is for; (b) dose and frequency; (c) precautions to follow while taking the drug, and contraindications for using the drug; (d) what to do if a dose is missed; (e) what potentially serious side effects the patient should report to the physician; and (f) the mild or transitory side effects that need not be reported to the physician unless they persist. Document that this information was dispensed.

Information on drugs may be obtained from the drug manufacturer or from Internet sites such as the U.S. Pharmacopeia (www.usp.org) or the Institute for Safe Medication Practices (www.ismp.org).

Duplicate treatment doubles your risk.
Do not write a prescription for a condition another physician is treating, unless you also communicate with that physician and reach agreement about which one of you will provide future prescriptions and refills of this medication. Document the details of your discussion.

Informing colleagues about on-call prescriptions promotes continuity of care.
Develop an understanding with your on-call colleagues about prescription and refill limitations. When on-call, provide minimum refills. Inform colleagues when you have prescribed or refilled a medication for their patients.

Here are prescription refill recommendations from the American Academy of Family Physicians for treating physicians taking time off:

• Leave standing orders for prescription refills with the covering physician or with your nurse. This will help limit delays and confusion for patients needing medication in your absence.
• Have the nurse keep a master log of prescription refills that includes patient name, medication, dose and quantity refilled. Review the log upon returning to the office and record the information in patient charts, or consult the log during your next appointment with the patient.
• Give appropriate patients sufficient refills on chronic medications that are safe and do not require followup visits.
• If the requested medication has the potential for misuse, advise the covering physician to pull the patient’s chart to review the refill history, including phone message refills. When in doubt, the covering physician should give a partial refill to maintain the patient’s regimen until you return. Also, the covering physician may consider offering the patient an appointment that day to better understand his or her usage pattern.
• Covering physicians should refill prescriptions only if they are comfortable in their knowledge of the medication and the disorder it is intended to treat. It is acceptable and perhaps even more effective to say, “I’m not comfortable doing that” than “I won’t do that.” Where indicated, recommend and document appropriate subspecialty followup for the patient.
• If the covering physician is not familiar with the medication being refilled, he or she should look it up.

A good faith exam protects patients and physicians.
Be aware that a good faith exam is required prior to prescribing medications.

Prescribing only for conditions you usually treat and follow promotes patient safety and reduces liability.
Do not prescribe medications solely as a convenience to patients, or for conditions you do not ordinarily treat and follow. Refer these patients to their treating physician or another appropriate physician.

Monitoring adherence and efficacy ensures appropriate use.
Ask and document if patients are taking their medications as prescribed. (Ask patients how, not just if, they are taking their medications.) Before refilling medications, monitor for unexpected effects and document why the drug is still appropriate. With some drugs, efficacy may need to be determined by laboratory studies.

Safeguarding prescriptive authority protects patients and physicians.
Only physicians and certain other providers—such as osteopaths, dentists, podiatrists and optometrists—can prescribe medications. Some licensed mid-level professionals may issue drug orders or furnish medications under a physician’s supervision. At the physician’s direction, unlicensed personnel (medical assistants and other office staff) can transmit the physician’s prescription order or a refill authorization to a pharmacy.

Note: These principles are provided as risk management advice. They do not constitute a legal opinion, are not a substitute for legal advice and are not intended to determine the standard of care. The principles presented should not be considered inclusive of all proper methods of care or exclusive of other methods of care reasonably directed to obtain the same results. The ultimate judgment regarding the propriety of any specific procedure must be made by the physician in light of the individual circumstances presented by the patient.