Many prescriptions are now computer-generated, but may also be hand-written and paper-based. In many healthcare systems, nurses are responsible for medication transcription, which involves transferring the physician’s prescription order to the medication administration record. This must be done correctly because transcription errors, if undetected, can lead to errors in medication administration and harm the patient. Outsourcing medical transcription can ensure error-free documentation of physicians’ orders and allow nurses and other healthcare providers to focus on patient care.
Transcribing Medication Orders
Physicians prescribe medications based on the diagnosis. Licensed practical nurses or registered nurses are authorized to transcribe medication orders. When the transcripts reach the pharmacy, pharmacists dispense the prescribed medication volumes and doses. The medications are then administered to the patient.
It is critical to ensure accurate and timely transcription of the medication in the medication administration record. Following these basic guidelines when transcribing medication orders can prevent errors and ensure patient safety in medication administration:
- Writing legibly or typing correctly so that all concerned persons can read it.
- Transcribing exactly as the order is written by the practitioner and current prescription label on the medication container.
- Ensuring that medication orders are transcribed in the medication record at the time medication is ordered.
- Using only facility-approved abbreviations.
- Check the prescription order to ensure accuracy in the following details: patient name, date, medication, dose, route, time, documentation, reason, and response.
- Any doubts in the written or dictated prescriptions must be clarified with the physician who made the order.
However, in facilities where large volumes of medications are prescribed, even licensed nurses can make mistakes in transcribing medications.
Medication Transcription Errors
A 2019 study published in BMC Health Serv Res. (https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6729077/) focused on medication errors occurring at the medication transcription stage. The researchers listed the various interpretations of medication order transcription errors described by previous studies, which are as follows:
- Inconsistency between the physician medication order and the medication order transcribed
- Mistakes while transcribing medication orders from the previous prescribing step
- Incomplete and/or wrong transcription of a medication order
- Mismatch between the medication prescription and what was transcribed on the nurse’s administration form
- Discrepancies in the names of the drugs, their formulations, routes of administration, doses, dosing regimens, omission of drugs, or addition of drugs which were not ordered or prescribed
The researchers cited previous studies that reviewed errors that occurred at the medication transcription phase:
- One study found that nurses transcribed chemotherapy and non-chemotherapy related prescribed medications onto different sheets twice. In the first transcription stage, there were inaccuracies in 11.8% and 20.7% of the transcribed chemotherapy and non-chemotherapy medications, respectively.
- Another study found medication transcription errors in 16.9% and 13.8% of the 6583 and 5329 medications transcribed onto inpatient profiles and discharge charts, respectively.
- A teaching hospital based study found medication transcription mistakes in about 30% of the 558 opportunities for errors.
The BMC study researchers emphasized that medication transcription errors are particularly a matter of concern because “the different phases of prescription, transcription, dispensing, and administration occur in chain and, therefore, it is highly likely that if a medication was transcribed incorrectly, this error would go without interception and would most probably reach the patient and cause harm”.
In large hospitals, where larger volumes of medications are prescribed, there is an increased chance for errors and potential harms to the patients.
Prevent Medication Documentation Errors with Outsourced Medical Transcription Services
Today, medical practices and hospitals with high-volume transcription requirements outsource the task to ensure accurate and timely medical record documentation. Medical transcriptionists are trained and certified to transcribe medication orders and many other types of reports that physicians dictate. Reliable US based medical transcription companies put all transcripts through a stringent quality assurance process, and can provide error-free, HIPAA-compliant documentation at cost-effective rates.
MTS Transcription Services (MTS) provides real-time medical transcription services for hospitals, clinics, and individual physicians throughout the United States. The company has a team of skilled and experienced medical transcriptionists, editors and proofreaders that can meet the medical transcription needs of hospitals, physician practices, medical centers, and more.
