Winnipeg docs, staff, break rules for writing prescriptions

When it comes to using medications safely in Winnipeg hospitals, caregivers don’t always follow the rules intended to prevent errors.

Hospital staff report use of banned terms, unclear or illegible orders

When it comes to using medications safely in Winnipeg hospitals, caregivers don’t always follow the rules intended to prevent errors 2:37
When it comes to using medications safely in Winnipeg hospitals, caregivers don’t always follow the rules intended to prevent errors.
A study in the Winnipeg Regional Health Authority found that just over half of hospital staff surveyed said they had seen or used medication orders that were unclear or illegible.
Jan Coates, a pharmacist who co-authored the study and is the WRHA’s Regional Manager of Pharmacy, said more than half of hospital staff surveyed said they had seen or used medication orders that were unclear or illegible, a contributing factor to medical errors. (CBC)

In addition, the study found 61 per cent saw banned medication abbreviations at least twice per shift.

“What we learned was that people had a reasonable understanding of the fact that using  abbreviations and incomplete orders do lead to errors,” said Jan Coates , a pharmacist who co-authored the study and is the Regional Pharmacy Clinical Services Manager.

The results were published in 2013 in the Canadian Pharmacists Journal and were based on survey responses of 723 staff.

The study was a follow up to a policy adopted by the WRHA in 2007 banning the use of certain  acronyms, abbreviations, and symbols that contributed to errors in medications orders.

The researchers also did an audit of thousands of hospital prescriptions and found the banned terms used 26 per cent of the time.

“It has been documented throughout the literature, probably throughout the world quite frankly,  that this is a problem,” Coates said.

The WRHA tracks medication errors and received more than 2,000 reports of occurrences since the start of 2012.

Officials say the vast majority don’t result in injury, but sometimes they do. 

One death a year in Winnipeg region related to errors

The WRHA recorded 36 critical incidents related to medication errors during the past three years, including two patients who died.

“Those 36 critical incidents region-wide that were associated with a medication error resulted  in 55 recommendations,” said Dr. Brock Wright, WRHA Vice-President and Chief Medical Officer.
Illegible prescriptions may be a cliché, but they can contribute to serious pharmacy errors. (Winnipeg Regional Health Authority)

“We track those recommendations and we are assured those 55 recommendations have been acted upon,” he said. “From a regional perspective we would average about one death a year that's a critical incident related to medication,” Wright said.

“When you look at those critical incidents it's not always clear cut that the medication resulted in  the death. But a medication error was associated with the death,” he said.

Thursday CBC News reported a Winnipeg cancer patient, Karl Kollinger, was shocked to discover that after his surgery at the Health Sciences Centre he had been given intravenous medication intended for the patient in the bed next to his.

Kollinger’s wife, Marlene, discovered the error and confronted hospital officials about why her  husband had not been given a hospital wristband to properly identify him to staff.

“If you can't identify the patient, how do you know you're giving the right medication?” said Marlene Kollinger in an interview.

“Yes, [staff] are in a hurry and I understand that and I respect that. However, that extra two  seconds to check a bracelet? And if the bracelet’s not there -- dear heaven, get one on him!” she said. 

The Kollingers said they’re not aware of any harm Karl suffered from the error.

Another case of mistaken identity was reported to Manitoba Health two years ago in which  the wrong patient was taken for day surgery because patient verification procedure was not followed.

The case was recorded in a provincial report tracking critical incidents that result in harm to patients.

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The report doesn’t identify which Manitoba hospital was involved but it says the procedure was 
attempted and not completed.

The critical incident reports also look at medication errors, such as a newborn who suffered major injury after being given ten times the prescribed dose of morphine. 

In another case a patient struck by lightning went to hospital and was discharged with  incorrect medications, resulting in weakness, dizziness, and cardiac rhythm disturbance.
  • A patient in an intensive care unit received two medications at incorrect times, later suffering a drop in blood pressure and cardiac arrest.
  • A patient received an incorrect dose of medication over 18 days, leading to an extended hospital stay and blood transfusions.

Poor communication, illegible handwriting to blame for errors

“Medication errors are actually very common in Canada," said Dr. Ben Chan, who teaches  quality improvement at the University of Toronto.

"Sometimes they can be due to poor [communication] related to either illegible handwriting or not understanding a verbal instruction. Sometimes it can be related to confusion if you have two drugs that sound alike or two patients that sound alike or two patients that have exactly the same types of conditions on the same ward,” said Chan.

“Then there are errors related just to the whole process of how medications are packaged and 
dispensed,” he explained.
Dr. Brock Wright, WRHA Vice-President and Chief Medical Officer, said there is an average of one death a year from critical incidents related to a medication error. (CBC)

“It’s a complex process and there are lots of times where the medication may simply end up in the wrong place. Anybody that's opened their sock drawer and realized that their son or their wife's socks are in their drawer can appreciate what that means,” Chan said.

He said one solution could be to make sure the caregivers administering drugs don’t feel rushed  or distracted.

Chan also said the use of computerized medication order entry systems can help.

Coates said the WRHA has already put in place a computerized system at St. Boniface hospital  and has long range plans to implement such a system at all the Winnipeg hospitals.

She said the WRHA is planning to do another audit of medication orders in the coming year to see whether staff members are following the rules on avoiding error-prone abbreviations and symbols.

Coates’s study also found what it termed an “unexpectedly high” level of support among hospital  staff in the survey for placing sanctions on prescribers who don’t follow the rules.

The WRHA said it is making improvements to the software it uses to track occurrences and critical incidents to make learning from them easier.

Chan suggested cutting down on medication errors won’t be easy.

“The bottom line is that all of these solutions require that leaders in hospitals make this a priority and pay top attention to the problem,” said Chan.

WRHA's banned abbreviations for prescriptions

The following is a poster of banned abbreviations, acronyms and symbols from the Winnipeg Regional Health Authority. (WRHA)


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