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What’s New in the Patient Safety World

August 2019

Including Indications for Medications:

We Are Failing

 

 

In our December 18, 2018 Patient Safety Tip of the Week “Great Recommendations for e-Prescribing” and several other columns we’ve stressed the importance of 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” 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 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. So, if the pharmacist saw an order for daily methotrexate and the indication was “rheumatoid arthritis”, the pharmacist might recognize the dosing error.

 

Over 15 years ago, when we were doing introduction to patient safety for all incoming residents in the SUNY Buffalo system, we began including a slide stressing how inclusion of indication for a medication can help reduce medication errors. We’re, of course, not the only ones calling for this simple, yet frequently overlooked, patient safety intervention. ISMP (ISMP 2010) stressed this in its guidelines for standard order sets (see our March 23, 2010 Patient Safety Tip of the Week “ISMP Guidelines for Standard Order Sets”). And Schiff et al. made a plea to incorporate indication into medication ordering in a New England Journal of Medicine piece in 2016 (Schiff 2016). And it was one of the key elements in the article by Schiff et al. (Schiff 2018) that we highlighted in our December 18, 2018 Patient Safety Tip of the Week “Great Recommendations for e-Prescribing”.

 

So how are we doing in getting medication indication incorporated into medication orders or prescriptions? A recent study (Salazar 2019) says not so good. Salazar et al. extracted free-text sigs from all outpatient prescriptions generated by the computerized prescriber order entry system of a major academic institution during a 5-year period. They then used natural language processing to identify drug indications. In over 4 million prescriptions, they found indications were included in only 7.41%.

 

77.18% of those which included the indication were written for PRN orders. Somewhat surprisingly, the highest rate of including indication was by orthopedic surgery providers (33.41%), whereas the rate for internal medicine prescribers was only 6.26%. Pain was the most common indication, accounting for 30.35% of all documented indications. Non-PRN chronic medication prescriptions rarely included the indication.

 

So, we’re not doing so well. Since almost all prescribing and ordering medications today is via computer (through CPOE or ePrescribing systems), the solution needs to be a technological one. Those systems need to prompt all clinicians ordering medications for the indication. They should have drop-down lists of common reasons for ordering such medications but would also need an “other” category for entering free text if the indication is something other than the common ones presented. While you always like to avoid free text entries, you might not be able to predict what the entry might be. So, there need to be alerts for identifying mistakes in that latter circumstance. For example, in the scenario we mentioned above when the clinician mistakenly orders “Dilaudid” instead of “Dilantin”, the script for an alert would have to recognize “seizures” or “epilepsy” in the free text entered under “other”. Moreover, it would have to recognize typos, so it would have to employ natural language processing or similar tool to recognize those words. In addition, all the standing order sets in your system will need to be redone to include indications for any medications included.

 

So, you can see a lot of work needs to be done!

 

And while we are talking about requiring an indication for all medications, we’d also like to take the opportunity once again to make our plea for including a “reason for discontinuation” when drugs are discontinued. 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, I might consider prescribing a beta blocker for migraine prophylaxis and the patient tells me that he/she was once on that medication. It would be important for me to know whether it had been discontinued because it was ineffective for the initial indication (other than migraine prophylaxis) or because of an untoward side effect or true allergy.

 

See also our August 6, 2019 Patient Safety Tip of the Week “Repeat Adverse Drug Events”.

 

 

References:

 

 

ISMP (Institute for Safe Medication Practices). Guidelines for Standard Order Sets. January 12, 2010

https://www.ismp.org/guidelines/standard-order-sets

 

 

Schiff GD, Seoane-Vazquez E, Wright A. Incorporating indications into medication ordering—time to enter the age of reason. N Engl J Med 2016; 375(4): 306-309

https://www.nejm.org/doi/full/10.1056/NEJMp1603964

 

 

Schiff G, Mirica MM, Dhavle AA, Galanter WL, et al. A Prescription For Enhancing Electronic Prescribing Safety. Health Affairs 2018; 37(11): 1877-1883

https://www.healthaffairs.org/doi/full/10.1377/hlthaff.2018.0725

 

 

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

 

 

 

 

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