phr
Bluelighter
Prescription's scrawled signature, jumbled numbers land well-intentioned Portland woman in jail
Andy Dworkin
The Oregonian
4.4.10
If you wonder why more and more doctors prescribe drugs electronically, ask Catherine Hoagland.
The Portland woman was jailed for several hours on Monday when she tried to help her nephew by filling a prescription at a local Rite-Aid. Officers thought the prescription was faked. It wasn't. Instead, Hoagland was derailed by a series of errors, including one that's almost a punch line: Bad doctor handwriting.
"The gist of it is, the practitioner, her name was not legible," said Lisa Vance, chief executive of Providence Portland Medical Center, where Hoagland's nephew was treated. "We feel terrible, actually mortified, at the fact that this poor woman was questioned and detained about this."
Like many errors in medicine, and life, several small failures collided in a busy, distracting environment. Hoagland's sister, Hope Arias, took her 19-year-old son Andrew Chandler to the ER with intense pain and a face swollen from an infected tooth. Doctors prescribed an antibiotic and pain killer in easy-to-swallow liquid form. But those elixirs must be hand-made and are expensive -- roughly $300, Arias said.
When Arias went back to get prescriptions for cheaper pills, a nurse practitioner paused in the busy ER to help. Three things went wrong: The practitioner's signature was unreadable. She mixed up digits in the federal registration number doctors need to prescribe narcotics. And the new prescription wasn't immediately logged into the patient record.
"It was human error," Vance said.
Since Arias is disabled, Hoagland went to fetch the medicine. Pharmacists questioned the prescription and phoned the hospital, faxing over a copy. A nurse found no record of the number or prescription and couldn't read the practitioner's name, so the pharmacy called the sheriff.
Hoagland was smoking outside the pharmacy when officers came to handcuff her. She was booked into jail for tampering with drug records, given a small brown sack lunch and one phone call. Bail was set at $750.
"It was stressful," Hoagland said. "I've never been arrested before in my life."
Arias, officers and the hospital figured out the problem, and Hoagland was released several hours later. Charges were dropped Thursday. Vance said Providence is offering to help Hoagland have the arrest expunged from her record, to pay for Chandler's care and help him get the dental work he needs.
Providence is working on steps to prevent such errors, Vance said. The ultimate solution may be replacing paper pads with electronic prescriptions. While the ER still uses paper pads, Vance said, about 85 percent of Providence Portland's inpatient system is electronic and the whole hospital hopes to use "eScripts" by next year. Those prescriptions don't have handwriting and are automatically recorded.
Other doctors and hospitals are moving toward electronic prescribing, and the government has offered stimulus money to help fund those changes. Studies show electronic prescriptions often reduce errors, though they may add a few new kinds of mistakes, depending on the systems' design. For instance, doctors may click the wrong item in systems with drop-down menus.
"I'm so sorry to the aunt," Vance said. "This should not have happened and we are working to make sure this doesn't happen again."
Link!
Andy Dworkin
The Oregonian
4.4.10
If you wonder why more and more doctors prescribe drugs electronically, ask Catherine Hoagland.
The Portland woman was jailed for several hours on Monday when she tried to help her nephew by filling a prescription at a local Rite-Aid. Officers thought the prescription was faked. It wasn't. Instead, Hoagland was derailed by a series of errors, including one that's almost a punch line: Bad doctor handwriting.
"The gist of it is, the practitioner, her name was not legible," said Lisa Vance, chief executive of Providence Portland Medical Center, where Hoagland's nephew was treated. "We feel terrible, actually mortified, at the fact that this poor woman was questioned and detained about this."
Like many errors in medicine, and life, several small failures collided in a busy, distracting environment. Hoagland's sister, Hope Arias, took her 19-year-old son Andrew Chandler to the ER with intense pain and a face swollen from an infected tooth. Doctors prescribed an antibiotic and pain killer in easy-to-swallow liquid form. But those elixirs must be hand-made and are expensive -- roughly $300, Arias said.
When Arias went back to get prescriptions for cheaper pills, a nurse practitioner paused in the busy ER to help. Three things went wrong: The practitioner's signature was unreadable. She mixed up digits in the federal registration number doctors need to prescribe narcotics. And the new prescription wasn't immediately logged into the patient record.
"It was human error," Vance said.
Since Arias is disabled, Hoagland went to fetch the medicine. Pharmacists questioned the prescription and phoned the hospital, faxing over a copy. A nurse found no record of the number or prescription and couldn't read the practitioner's name, so the pharmacy called the sheriff.
Hoagland was smoking outside the pharmacy when officers came to handcuff her. She was booked into jail for tampering with drug records, given a small brown sack lunch and one phone call. Bail was set at $750.
"It was stressful," Hoagland said. "I've never been arrested before in my life."
Arias, officers and the hospital figured out the problem, and Hoagland was released several hours later. Charges were dropped Thursday. Vance said Providence is offering to help Hoagland have the arrest expunged from her record, to pay for Chandler's care and help him get the dental work he needs.
Providence is working on steps to prevent such errors, Vance said. The ultimate solution may be replacing paper pads with electronic prescriptions. While the ER still uses paper pads, Vance said, about 85 percent of Providence Portland's inpatient system is electronic and the whole hospital hopes to use "eScripts" by next year. Those prescriptions don't have handwriting and are automatically recorded.
Other doctors and hospitals are moving toward electronic prescribing, and the government has offered stimulus money to help fund those changes. Studies show electronic prescriptions often reduce errors, though they may add a few new kinds of mistakes, depending on the systems' design. For instance, doctors may click the wrong item in systems with drop-down menus.
"I'm so sorry to the aunt," Vance said. "This should not have happened and we are working to make sure this doesn't happen again."
Link!
