Help for detecting doctor mental slips on prescriptions


The Institute for Safe Medication Practices, which operates, has long promoted the importance of doctors including the reason for each medication right on the prescription given to you to take to the pharmacy. This critically important step helps to prevent wrong drugs from accidentally being dispensed. There are, for example, many drug names that look-alike or sound alike when prescriptions are telephoned to the pharmacy.

Although mix-ups are quite rare, they do happen if handwriting is less than clear or if an oral communication by telephone is misheard. They also happen because of mental slips.

Here's an example of a near miss that was reported to us recently. A physician accidentally prescribed hydrALAZINE, a drug for high blood pressure instead of hydrOXYzine, a drug used for allergies. These medications have names and strengths that are similar. The patient had a rash and was itching so the doctor really meant to prescribe hydrOXYzine not hydrALAZINE.

In this case, the pharmacist was immediately able to recognize that the physician had made a mental slip. Why? Because the doctor included the reason for the medication - itch - right on the prescription and the pharmacist knew hydralazine was never to be used for itch. In fact, had hydralazine been dispensed, the patient may have suffered very low blood pressure and serious side effects. The pharmacist contacted the prescriber and had the order changed.

There’s a grateful patient out there somewhere, simply because her doctor put the reason for the medication right on the prescription. Be sure to ask your doctor to do the same every time a prescription is written. It's definitely the safe thing to do.

Created on December 19, 2008

Medication Safety Alerts

FDA Safety Alerts

Show Your Support!

ISMP needs your help to continue our life saving work