View as “PDF version”
Patient Safety Tip of the Week
March 7, 2023
One of Our Pet
Peeves: Lack of Indication on Medications
Since the early
1990’s we’ve stressed how inclusion
of indication for a medication can
help reduce medication errors. In our December 18, 2018 Patient Safety Tip of
the Week “Great
Recommendations for e-Prescribing”
we gave several reasons for including the indication for a medication
when entering a prescription or order for a medication. Providing the indication
for a prescription is important for more than one reason.
First, there are
many medications that are used for treating multiple conditions. For example,
beta blockers may be used in the treatment of MI, CHF, migraine, essential
tremor, hypertension, etc. Knowing the reason for the initial prescription,
thus, is important when decisions about discontinuation are being pondered.
Second, seeing the indication may help a pharmacist recognize when a wrong drug has been prescribed. That is especially
important when LASA (“look-alike, sound-alike”) errors are made. For example,
if a prescriber erroneously clicked on “Dilaudid” instead
of “Dilantin” in a drop-down list but a pharmacist saw the indication was “for
seizures”, the pharmacist would recognize a problem and contact the prescriber
for clarification. The same concept should be used at the time of order entry
to prevent prescribing the wrong medication. In the example above, if you
looked for “seizures” as an indication in a drop-down box under the erroneously
chosen “Dilaudid” you’d realize you had chosen the
wrong drug.
Third, seeing the
indication can help avoid wrong-dosing errors. For example,
we’ve discussed the methotrexate problem in multiple columns. That is when
methotrexate is ordered for treating an autoimmune condition, like rheumatoid
arthritis, rather than for oncologic conditions. For the former, once weekly
dosing is used rather than daily dosing. So, if the pharmacist saw an order for
daily methotrexate and the indication was “rheumatoid arthritis”, the
pharmacist might recognize the dosing error. Or there may be implications for
duration of use of a drug. For example, knowing the indication for an
antibiotic is for prophylaxis for a surgical procedure rather than for treatment
of an established infection could prevent a patient from getting multiple days
of unnecessary antibiotic that could lead to superinfection or resistance or
other problem.
Fourth, it may help
even with longer term medication management. Let’s say I am doing medication
reconciliation at a transition of care, or I am doing an annual “brown bag”
medication review on a patient, and I see they are taking a proton pump inhibitor
(PPI). Knowing whether that PPI was prescribed for GERD or whether it had been started
as prophylaxis while that patient had been in an ICU would be extremely
important (and many patients might not be able to answer that question
themselves).
In our May
24, 2022 “Requiring Indication for
Antibiotic Prescribing” we discussed one area where including the
indication is particularly important – prescribing antibiotics. Knowing exactly
why or for what infection the antibiotic is being ordered can be an important
part of every antibiotic stewardship program, whether at the hospital or
clinic/office. An antibiotic stewardship program can help determine whether the
specific antibiotic, dose, or duration is appropriate for the intended
infection.
The core elements of CDC’s “Core Elements of Hospital
Antibiotic Stewardship Programs” (CDC 2019)
include documentation of dose, duration, and indication for all antibiotic
orders. CDC notes that requiring an indication for antibiotic prescriptions can
facilitate other interventions, like prospective audit and feedback and
optimizing post-discharge durations of therapy, and, in and of itself, can
improve antibiotic use.
But there is little in the literature on the importance of
including the indication for many other medications. A recent systematic review (Feather
2023) looked at indication
documentation and indication-based
prescribing within
electronic prescribing
systems. Feather et al. identified
21 studies describing interventions to support indication documentation
via two mechanisms: indication
documentation via selection from a list
or as free text, and/or via use
of indication-based order
sentences.
Outcomes studied were diverse and included prescribing workflow, reducing prescribing errors, aiding transfer of information
between healthcare professionals, and
facilitating patient education.
Six of eight studies showed a positive
effect on “appropriateness of medication”. Other studies demonstrated improvements in
prescribing error rates, improved glycemic control, reduced length of stay, reduced time to
complete medication orders and
reduced number of prescriptions requiring
pharmacy intervention.
The included studies
also noted barriers to inclusion of the indication. Long drop-down lists, in particular, made selection difficult and risked mis-selection. Some considered including the indication to be
time consuming. Prescribers often needed to use workarounds to navigate approval systems due to time or knowledge constraints. Prescribers also often seemed to prioritize
dose and frequency over selection of an accurate
indication.
For clinical,
administrative, and research purposes selection of a specific indication from a
drop-down list makes sense. This is preferable to entry of the indication via
free text. However, it is difficult to get around the need for an “Other”
category on such lists where prescribers can input text. If you do include an “Other”
category, you should review the text responses in that category every few
months to identify responses that occur with sufficient frequency to merit
their own spot in a drop-down list.
In our May
24, 2022 “Requiring Indication for
Antibiotic Prescribing” we noted Saini et al. (Saini
2022) had done a literature review on documentation of the indication for
antimicrobial prescribing. They identified 123 peer-reviewed articles and grey
literature documents for inclusion. Most studies took place in a hospital setting
(89%). The median prevalence of antimicrobial indication documentation was 75%
(range 4%–100%). A benefit to prescribing or patient outcomes was identified in
17 of 19 studies that looked at these end points. They note that several
studies have shown that multipronged approaches can be used to improve this
practice and that emerging evidence demonstrates that antimicrobial indication
documentation is associated with improved prescribing and patient outcomes in both
community and hospital settings. However, they concluded that setting-specific
and larger trials are needed to provide a more robust evidence base for this
practice.
Equally important is the need for documenting reasons for
discontinuations of medications. We discussed this in our August 2019 What's
New in the Patient Safety World column “Including Indications for
Medications: We Are Failing” and multiple other columns listed below.
It may be important to know whether a
medication was discontinued because of:
· Ineffectiveness
· Side effects (dose-related or
non-dose-related)
· Allergy (true allergy)
· Adverse event
· Cost considerations
· Other
For example, a
patient comes to me with essential tremor. I’m considering prescribing propranolol
for that tremor. The patient tells me that he/she was once on propranolol for migraine
prophylaxis. It would be important for me to know whether it had been
discontinued because it was ineffective for the initial indication (migraine
prophylaxis) or discontinued because of an untoward side effect or true
allergy.
Not only do we lack
systems for documenting reasons for discontinuation, we also often fail to
notify all who need to know a drug has been discontinued. The columns listed
below have all dealt with the issue of documenting drug discontinuation, not
only to other potential prescribers for a patient, but also to pharmacies that
might continue to dispense drugs that had been discontinued. And keep in mind
that, even if your CPOE or ePresribing software
includes a field for “reason for discontinuation” there must be a mechanism for
transmitting that information to pharmacies.
Our August 2019 What's New in the Patient Safety World
column “Including Indications for
Medications: We Are Failing” cited a study (Salazar
2019) that found indications included in only 7.41%, of over 4 million
prescriptions. We don’t know of any updated statistics since that article, but
our own experience is that we are still far behind in achieving what should be
a “no brainer” for patient safety.
Some of our other
columns on including indication for medication orders:
March 23, 2010 “ISMP
Guidelines for Standard Order Sets”
December 18, 2018 “Great
Recommendations for e-Prescribing”
August 2019 “Including Indications for
Medications: We Are Failing”
March 1, 2022 “Including the Indication on
Prescriptions”
May 24, 2022 “Requiring Indication for
Antibiotic Prescribing”
Some of our other
columns on failed discontinuation of medications:
May 27, 2014 “A
Gap in ePrescribing: Stopping Medications”
March 2017 “Yes!
Another Voice for Medication e-Discontinuation!”
February 2018 “10
Years on the Wrong Medication”
August 28, 2018 “Thought
You Discontinued That Medication? Think Again”
December 18, 2018 “Great
Recommendations for e-Prescribing”
August 2019 “Including
Indications for Medications: We Are Failing”
August 6, 2019 “Repeat
Adverse Drug Events”
October 2021 “Tool
to Prevent Discontinued Medications from Being Dispensed”
October 11, 2022 “Good Intentions, Unintended
Consequences”
References:
CDC (Centers for Disease Control and Prevention). Core
Elements of Hospital Antibiotic Stewardship Programs. CDC 2019
https://www.cdc.gov/antibiotic-use/core-elements/hospital.html
Feather C, Appelbaum N, Darzi A, et al. Indication
documentation and indication-based prescribing within electronic prescribing
systems: a systematic review and narrative synthesis. BMJ Quality & Safety 2023;
Published Online First: 14 February 2023
https://qualitysafety.bmj.com/content/early/2023/02/13/bmjqs-2022-015452?rss=1
Saini S, Leung V, Si E, et al. Documenting the indication
for antimicrobial prescribing: a scoping review. BMJ Quality & Safety 2022;
Published Online First: 12 May 2022
https://qualitysafety.bmj.com/content/early/2022/05/12/bmjqs-2021-014582
Salazar A, Karmiy SJ, Forsythe KJ,
et al. How often do prescribers include indications in drug orders? Analysis of
4 million outpatient prescriptions. American Journal of Health-System Pharmacy
2019; 76(13): 970-979
https://academic.oup.com/ajhp/article-abstract/76/13/970/5519760?redirectedFrom=fulltext
Print “PDF version”
http://www.patientsafetysolutions.com/