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Risk Management Tips: Prescription Medications and Patient Safety
The Tip:
Educating patients about their prescription medications and keeping medical records updated with prescription information both help to ensure patient safety.
The Risk:
Patient injuries and malpractice claims can result from known risks and side effects, allergic reactions, drug interactions or errors in prescribing.
Recommendations:
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.
