Improving legibility and converting to electronic prescription systems top the recommendations from a blue-ribbon panel on medication mistakes in California.


A particularly dangerous hazard is posed by what the panel called “look-alike/sound-alike” medications such as quinine and quinidine. One is used to treat malaria; the other, cardiac arrhythmias. Clearly written or typed prescriptions would avoid confusion. The group also urged that the purpose of a drug be included on the label.

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Sponsored by the California Pharmacists Association, the 15-member panel was composed of physicians, pharmacists, and pharmaceutical industry and consumer representatives, among others. Their study found that mistakes are preventable and can occur at any point, including prescribing, transcribing, dispensing, using, and monitoring.


But patients were blamed for many errors. They “typically take less than half the prescribed doses,” the report said. Poor health literacy was another factor. Even when people had correctly read and repeated instructions in the presence of a doctor, they may not have been able to follow them.


Multiple medications, especially when prescribed by multiple providers, increased the chances for errors in administration. Patients who used more than one pharmacy added another layer of risk by subverting protection from computerized screening programs. 


As a result of these findings, many of the 12 recommendations dealt with consumer education about a drug’s correct use, risks, and benefits. Nonetheless, “improving communication between the physicians and the pharmacists can play a large role in reducing medication errors and saving lives,” said Lynn Rolston, the pharmacist association’s CEO.