Educating patients about their prescription medications and keeping medical records updated with prescription information both help to ensure patient safety.
Patient injuries and malpractice claims can result from known risks and side effects, allergic reactions, drug interactions or errors in prescribing.
MLMIC offers the following guidelines/suggestions to physicians and dentists regarding prescription medications and patient safety.
- Since there are significant risks and side effects associated with prescribed drugs, physicians and dentists must discuss this information with their patients and document these discussions in the medical record.
- The patient’s allergic history must be reviewed before a new drug is prescribed. Known allergies must be documented and flagged in a prominent, easily viewable place in the medical record.
- Medication updates, including dosage changes and refills, and the use of any over-the-counter drugs, must be clearly documented in the medical record. A medication flow sheet can be used to monitor and track current and past medication usage, as well as allergies.
- Any specific instructions provided to patients regarding the medications must also be written in the record.
- There must be written confirmation that the laboratory and/or diagnostic tests necessary to monitor certain drugs for their effectiveness or side effects are ordered, as recommended by professional guidelines, and the test results viewed and necessary adjustments made.
- The rationale for the discontinuing a medication must be documented in the medical record.
Risk Management Tips provide guidance to support our physicians and facilities in their ongoing efforts to improve the quality of patient care and reduce liability exposure in the practice of medicine. Please contact MLMIC’s Risk Management Department at (800) 275-6564, weekdays 9:00 AM – 5:00 PM, for guidance regarding your specific situation.