While the use of electronic prescribing is known to improve provider workflow and patient safety, many errors occur when entering an important data segment, leaving patients at risk. These mistakes occur when entering the dosing and usage instructions, otherwise known as the sig. In this article, we’ll discuss the ramifications of sig mistakes, and how prescribers can prevent them using the tools already available to them, such as structured and codified sig.
What is Structured and Codified Sig?
As incorporated in the NCPDP SCRIPT standard, structured and codified sigs are a standardized method of communication for prescription-related information between providers, pharmacists, and patients.
In short, e-prescribe software takes prescriber instructions and “translates” them (by converting them to relevant codes) into a common language for pharmacists and patients.
Prescribers always get to review the structured sig before the prescription is sent. Then, because it has been codified into a common language, the instructions to the pharmacist and patient can be automated and standardized.
The common language at the core of structured and codified sigs is the Universal Medication Schedule (UMS).
UMS works in tandem with the SCRIPT standard and is described as:
“A methodology that simplifies medication administration instructions for the patient and/or their caregiver. The goal of UMS is to increase patient understanding and adherence to their medication instructions, thus resulting in improved health outcomes.”
What is the Purpose of Structured and Codified Sig?
Structured and codified sig features in e-prescribing software improve patient safety and provider workflows. This is done by minimizing the risk of adverse drug events (ADEs) and medication-related harms from prescribing errors, incorrect medication dispensing, and patient mistakes.
While at face value, medication directions may not seem as complicated as something like drug interactions—a poorly worded or unclear sig can result in significant harm.
Some examples of sig-related harm include:
- A patient taking the wrong dose of medication
- The pharmacy dispensing the wrong drug or formulation
- Using an incorrect route of administration
- Taking medications at the wrong time of day
- Excessive use of PRN or non-daily medications
- A longer or shorter course of treatment than intended
These events have real ramifications. According to the Office of Disease Prevention and Health Promotion (OASH), each year, adverse drug events (ADEs) and harms from medication:
- Cause 1.3 million emergency department visits
- Lead to 350,000 hospitalizations
- Result in $3.5 billion in excess medical costs
Reducing ADEs requires a multi-pronged approach. But one of the logical places to start is at the point of prescription, with ensuring accurate and unambiguous dosing and usage instructions using structured and codified sig.
How E-Prescribe Software Automates Sigs
To understand how structured and codified sigs might work in e-prescribe software, consider the different possible interpretations of the commonly used “1 qd” instruction on a prescription.
According to the Unified Medication Schedule (UMS), this might be interpreted by the receiving pharmacist as:
- Take one tablet once daily
- Take 1 tablet 1 time per day
- Take one tablet each morning
- Take one tablet every 24 hours
However, when processed by e-prescribe software—through the assistance of integrated structured and coded sigs—administration instructions are standardized to provide explicit timing with defined intervals (e.g., morning, noon, evening, bedtime).
So, with automation and prescriber prompting, “1 qd” would be restructured, codified, and communicated to the pharmacist and patient as:
“Take 1 pill in the morning (or time specified by the prescriber).”
Also, any number of variations of the same sig by different prescribers would be codified and communicated as that consistent, structured instruction.
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Structured Sig Best Practices
Here are our top 8 suggestions to improve the accuracy, efficiency, and safety of prescriptions and medication order writing (adapted from NCCMERP):
While we’re not suggesting you avoid conversations about medication instructions, written orders are always preferable to verbal ones. If you’re on a phone call with a pharmacist, counseling a patient, or directing nursing or care staff—always follow up with written instructions as soon as possible.
The most common offender here is “take as directed,” but “until the course is finished” would be a close second. Always err on the side of being more specific rather than less. For example, “Take 1 tablet morning and one tablet evening” is preferable to “1 tablet twice a day.”
Yes, we’re aware we broke this rule by using the term sigs! But avoiding abbreviations and Latin in medication directions can dramatically decrease dispensing errors and patient mistakes. Abbreviations like “U” for units, “SQ” or SC” for subcutaneous, and countless others are often the precipitating factor in medication mistakes and adverse drug events. It is especially important to avoid abbreviating drug names, which can easily be confused.
Unless it’s warranted for patient confidentiality, including the indication (e.g., for hypertension, or to treat chest infection) adds an extra layer of protection against errors. When the purpose is included on the prescription, both pharmacist and patient are more likely to pick up if an incorrect drug has been provided.
Like including the indication, patient education also acts as an extra safety measure. Plus, just as important, it can significantly improve medication adherence. Counseling for patients, caregivers, and family members is particularly important for high-risk drugs like hypoglycemic agents and anticoagulants.
The most common errors in pediatric and geriatric populations relate to errors based on age and/or weight. Including the age and weight of a patient will help to dispense professionals double-check that the appropriate dose is being administered.
With the widespread use of comprehensive EHRs, ideally, all providers should have access to adequate information about the patient before prescribing. This would include information like current medications, allergies, diagnoses, prescription monitoring program data, and a treatment plan. In most circumstances, the safest option is to hold off prescribing until you can access a patient’s full relevant background history.
If you are using a decimal expression of less than one, always precede the dose with a zero (use 0.8mg instead of .8mg). Conversely, never use a zero after a decimal (use 8mg instead of 8.0mg). Ten-fold medication errors have occurred and are likely to have serious adverse consequences.
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ePrescribing presents many benefits that can improve provider workflow and patient safety. However, if best practices aren’t followed, mistakes can still be made, leading to prescription inaccuracies and patient safety risks. To ensure you are benefiting from the full capabilities of ePrescribing, follow the best practices outlined in this article. For more information on structured sig adherence and best practices, download our white paper SIGS – How Automation Happens in E-Prescribe and Best Practices.