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This newsletter provides feedback and sends reminders to prescribers about issues raised in
incidents, Walk Rounds and audits. It supplements MedicationMatters with a focus on safe
Writing a medication order is the main form of communicating prescribing,
dispensing and administering medicines. Orders need to be interpreted by many different healthcare
professionals across both hospital and community settings. Illegible orders cause delays, errors and harm.
Any unclear order must be re-written if requested by a staff member.
Some local examples
Some easy solutions
An illegible order led to a transcription error
Nifedipine was illegible. The order was re-
written as “Mirtazipine”. Both are available as
When writing medication orders ensure the
next prescriber can transcribe it correctly
Hydrochlorothiazide, Glyceryl trinitrate spray,
Digoxin 500 microgram stat
What are these
To prevent delays and errors in
administration of PRN and STAT orders
Never abbreviate the drug name
Write microgram in full
Dispense 10 or
Although 10mg was intended, the ‘g’ from the
sertraline dose made the diazepam dose look
like 40mg , which was dispensed.
Always re-read the script to ensure it can be
correctly interpreted by others
The dose is 210mg 230mg 250mg?
250mg was read and dispensed instead of the
intended 210mg. The error was picked up
before being administered.
( Chemotherapy agents have a high risk for
causing harm when incorrectly given. Any
handwritten orders MUST be unambiguous
What is the dose of perindopril?
The intended dose was 2.5mg, but was
transcribed and administered as 12.5mg
( Medication orders are a communication tool.
When re-writing charts, also check each order.
Ensure your orders can be interpreted
- all orders should be this legible!
For more information,
Look up the Alfred Safe Prescribing Guideline: http://intranet.alfredhealth.org.au/Assets/ContentFiles/1/MedicationManagementSafePrescribing.pdf
How useful is this newsletter? Your feedback is appreciated
Medication Safety Committee, Alfred Health. Medication Safety Pharmacist: (03) 9076 6330
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