Creating safe medication prescribing processes

Patient Safety Recommendations

Creating safe medication prescribing processes and systems is a critical component in reducing the risk of adverse drug events and medication errors. For physicians working in an ambulatory clinical delivery setting and prescribing controlled substances and nonscheduled medications, important aspects of prescribing processes include the following:

  • Conducting a thorough examination of the patient prior to prescribing medications or renewing prescriptions, especially for an opioid medication.
  • Obtaining a medication history on the initial visit, entering it onto a medication log or form, and placing it in the patient’s medical chart. Include prescription medications, over-the-counter medications, alcohol and drug use, vitamins, herbal products, dietary supplements, alternative medicine, and homeopathic medications.
  • Updating the medication history/medication log at each patient visit.
  • Providing the patient with an up-to-date list of medications at the end of each encounter.
  • Informing the pharmacy about the patient’s comorbid conditions, allergies, weight, and date of birth when calling in the prescription orders. Spell out drugs with similar sounding names. Determine when your prescription should include the indication for the medication, such as when ordering sound-alike medications, PRN medications, and high-risk medications, and apply consistently.
  • Preparing a prescription label for sample medications for the patient to take home. The label must meet state pharmacy regulations.
  • Providing medication counseling to the patient or caregiver with consideration given to any language or literacy barrier and to any hearing or sight impairment of the patient or caregiver. Use the Ask Me 3 guidelines or “teach-back” method to ensure patient understanding
  • Obtaining and documenting informed consent.
  • Monitoring medication usage closely, particularly for controlled substances.
  • Not storing drugs (sample medications or clinic medications) that look alike or sound alike adjacent to each other.
  • Documenting all medications administered to the patient during the clinic visit, including vaccines and sample medications.
  • Asking the patient about medication allergies or sensitivities to substances at each visit or at least yearly, and documenting the information on the medication log for easy access.
  • Providing education to the patient on his or her medications and on any potential interactions, such as with herbal and nutritional substances. Also include signs and symptoms of untoward reactions with medications and provide instructions on whom to call for further care.
About Roland

Roland was born in Nashville, Tennessee and raised in Mt. Juliet, Tennessee. The first few years he resided in Paris, France with his mother who was French. In Hendersonville, he attended Beech Senior High School where played soccer and studied in the honors curriculum. Subsequently, he pursued two majors in political science and economics while graduating in three years.

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