Reducing adverse events

Abstract

First paragraph: The form to which William MacLean refers in his letter was being used during our study,1 and we commonly saw problems with how the forms were completed. For example, it was often difficult to distinguish old from new medications, poor handwriting often made prescriptions illegible, and only rarely was a contact number for the prescribing physician indicated on the form. Thus, although the forms probably have a role in guiding physicians, time pressures and other factors lead to unsafe prescribing practices. Because the form was used for almost all patients, we are unable to determine whether the risk of adverse events decreased with its use.