This column was prepared by the Institute for Safe Medication Practices (ISMP), an ECRI affiliate.
ISMP has received numerous error reports related to the field for “Comments” or “Prescribers Note” on electronic prescriptions, particularly when used to express a different set of directions than what is included in the “Sig” field or to clarify the medication order. In a recent event, a specialty pharmacy reported that a provider ordered Depakote® (divalproex sodium) 500 mg extended-release tablets for a patient. In the Sig field, the directions read, “Take 5 Tablet By Mouth As Directed – See Instructions” (Figure 1). The prescriber also included more detailed instructions in the Prescribers Note field at the bottom of the prescription, which stated, “Take 1 tab by mouth every morning and 1 tab every evening and 3 tabs at bedtime.” Because the more specific instructions were included in the Prescribers Note field and not the Sig field, the pharmacy computer system did not automatically populate them and instead required manual entry. During the transcription process, the data entry technician missed part of the directions. The verification pharmacist did not catch the transcription error, and the prescription was dispensed with incorrect directions. The error was discovered at the first refill when the pharmacist double-checked the prescription directions against the original prescription. Thankfully, the patient was taking the medication correctly, as they had been on this regimen for quite some time.
Figure 1. A prescriber included instructions in the e-prescription’s Sig field (horizontal red arrow) and a more specific set of instructions in the Prescribers Note field (downward pointing red arrow).
We have received similar reports from community pharmacists. For example, a community pharmacy received an electronic prescription for the anticonvulsant gabapentin with “1 tablet PO TID” in the Sig field but “i po bid x7 days, then i po tid thereafter” in the notes field.
Using the comment or notes field to correct or modify electronic orders is problematic, as pharmacy staff may miss the information. Or, as in the case above, mistakes may be made when manually transcribing the information during data entry. ISMP recommends that organizations establish an escalation strategy for when staff and prescribers cannot enter the correct information (eg, dose, frequency) into the electronic prescribing system. If two sets of directions are seen on an electronic prescription (ie, in the sig and in the notes), pharmacy staff should seek clarification from the prescriber prior to dispensing. Pharmacists should inform and educate prescribers when potential or actual errors are encountered as a result of using the comments or notes field.