Patient Safety Tip
of the Week
August 28, 2018
Thought You
Discontinued That Medication? Think Again
In our February 2018
What's New in the Patient Safety World column “10
Years on the Wrong Medication”
we noted a case in which a patient was inadvertently continued on a wrong
medication for 10 years! That case illustrated how the medical record
(either electronic or paper) can propagate medication errors over a long run
and that medication reconciliation is not infallible (since several
opportunities to identify this error failed to do so). It also emphasizes the
need for regular comprehensive reviews of medication regimens (such as the
annual “brown bag” review) the need for a communication other than a discharge
summary or letter in order to ensure that an incorrect
or unnecessary medication is not restarted.
In our May 27, 2014
Patient Safety Tip of the Week “A
Gap in ePrescribing: Stopping Medications” and
our March 2017 What's New in the Patient Safety World column “Yes!
Another Voice for Medication e-Discontinuation!” we highlighted what we consider to be a
major flaw in current e-prescribing systems, namely that they do not put the
same emphasis on stopping medications as they do on starting them.
But now we find out that medications often get
inappropriately continued even after they have been discontiniued
in CPOE and e-prescribing systems!
In our May 27, 2014
Patient Safety Tip of the Week “A
Gap in ePrescribing: Stopping Medications” we
discussed a study done in a large multispecialty group practice in
Massachusetts (Allen 2012) which showed that, among targeted
medications that were electronically discontinued (on the practice’s EMR), 1.5%
were subsequently dispensed by a pharmacy at least once. And this was just at
the practice’s internal pharmacy. How often this happened at community
pharmacies was not known. Moreover, when they did manual chart reviews of
selected high-risk medications that had been discontinued they found that 12%
of cases (50 cases) were associated with potential harm. The latter cases
included clinical reactions (n = 18), laboratory abnormalities (n =
17), duplicated medication classes dispensed (n = 8), and potential
allergic reactions (n = 7). The authors noted that when a physician
discontinues a medication on an EMR he/she often (erroneously) assumes that
such information is being transmitted to the pharmacy. Such is seldom the case
with today’s EMR systems. Further, many pharmacies today have sophisticated
systems that let you know, as a patient, that you have a refill waiting for you
at the pharmacy. Patients may erroneously presume that their physician
restarted that medication.
Now a new study (Copi
2018) looked at a year’s worth of electronic
prescriptions for hypotensive, hypoglycemic, anticoagulant, antiplatelet, and
statin medications picked up from 3 outpatient pharmacies within the health
system. Prescriptions must have been written by a Michigan Medicine health
system provider and were excluded if they were written, faxed, or phoned in.
They were able to determine the temporal relationship of the order for
discontinuation and the pharmacy dispensing by comparing timestamps. They found
that 4.94% of over 10,000 prescriptions were picked up at the pharmacies after
the prescription order was discontinued in the HER. The prescription was
discontinued before final pharmacist verification for 54.56% of those prescriptions.
Inadvertently dispensed prescriptions may have contributed to hospital
admission 30 days after pick-up for 3 individual patients.
Copi et al. note that electronic
message transmission systems to relay changes or cancellations in prescriptions
from the prescriber to the pharmacy do exist and may even allow prescribers to
send messages to the pharmacy for prescriptions that were handwritten, not just
electronically prescribed, But the prescriber must know which pharmacy filled
the handwritten prescription and both the EHR and pharmacy dispensing software
must be compatible with this function and activate it for this transmission to
be useful.
Much like the previous study, the pharmacies in this study
were part of the health system. Therefore, the pharmacists had access to the
system’s EMR. That health system has now asked all its outpatient pharmacists
to perform a check of the patient’s current medication list to ensure that the
prescriptions being filled are still active and accurate in the EMR. But the
authors recognize that such would only have the potential to catch about 50% of
the errors that were observed, because about 50% of these prescriptions were
discontinued before the pharmacist verification step. They acknowledge that
such check of the EMR also adds an extra step to the pharmacist workflow, and may add considerable time. We all know that
time pressures are one factor that significantly increases the risk for errors
in pharmacies. They note that pharmacy technicians might be used to participate
in medication reconciliation. They also note that inclusion of a pharmacist in
the interdisciplinary discharge planning meetings could facilitate letting the
outpatient pharmacies know about medication discontinuations.
We always advise patients to keep a list of their current
medications with them. That obviously requires frequent updating of the
medication list, not only to include new medications but also to exclude
discontinued medications. Pharmacists at the outpatient pharmacies should
review those updated lists with their own lists of the patients’ medications.
The problem is likely even worse
when you consider that most community pharmacies are not integrated into health
systems. Some community-wide health information exchanges (HIE’s) or regional
health information organizations (RHIO’s) do provide electronic linkages between
the health systems, hospitals, and pharmacies but these are not universal. The
problem is also amplified when you consider that patients may be receiving medications
at more than one pharmacy or from an online pharmacy. Online pharmacies, chain
pharmacies, and community pharmacies are often contacting patients by multiple
means (phone, email, smartphone apps, etc.) to remind them to refill their medications.
So the problem may be even more widespread
that in the Allen or Copi studies.
Of course, there is another significant issue that arises
when you discontinue a medication. In
our May 27, 2014 Patient Safety Tip of the Week “A
Gap in ePrescribing: Stopping Medications” we
highlighted what we consider to be a major flaw in current e-prescribing
systems, namely that they do not put the same emphasis on stopping medications
as they do on starting them. In that column we noted a case report in
the Medical Journal of Australia (Tong
2014) in which discontinuation of one medication led to excessive levels of
a different medication because there had been a drug-drug interaction. Most systems are not programmed to
generate any alerts at the time you discontinue a medication. Even if your
system would have generated a drug-drug interaction alert when you first prescribed
a medication, it would not likely generate an alert later when you discontinue
that medication. If such a drug-drug interaction had been active, the discontinuation
of one medication may raise or lower the blood levels or effectiveness of the
other medication.
We once again highlight a critical issue: stopping a medication is much different
than starting one. Starting a medication requires an active process – you
either write a prescription, enter one into a computer, or call the pharmacy. You
are usually in a situation where you can utilize an electronic order system
(CPOE or e-prescribing tool) and you may have access to the many clinical
decision support tools in those systems. But discontinuing a medication is
often more passive – you might get a call from your patient after hours and just
tell the patient over the phone to stop it when the patient tells about a
potential side effect. You don’t call the pharmacy to stop it. And, if there
was no associated office visit, you might even forget to update the patient’s
medication list in your EMR (or paper records) until the patient’s next office
visit.
With today’s integration of the EMR to the physician’s
smartphone, almost all opportunities to do e-discontinuation should be done
with a formal process that should include more than just the discontinuation order.
The EMR system could ask “Have you notified the patient to discontinue the
medication?”, “What is the reason for the discontinuation?”, and “Do you wish
to notify the patient’s pharmacy of the discontinuation?”. The system’s clinical
decision support tools should then also consider whether any drug-drug interactions
might be in play that would necessitate changing the dosage of another
medication.
And don’t forget there is one other mechanism by which
discontinued medications get inappropriately continued.
Our February 28, 2017 Patient Safety Tip of the Week “The
Copy and Paste ETTO” reminds
us how the copy/paste function in today’s healthcare IT systems can lead to
erroneous medication lists that might result in a patient being inappropriately
restarted on a medication that had actually been discontinued.
Lastly – back on our
soapbox! Just as we have advocated for inclusion of the indication for
new prescriptions, it is important that we always somehow record why we have
discontinued a medication. How often have you suggested a medication and
your patient says “yes, I was on that medication once" but can’t tell you
why they were taking it or why it was stopped. Was it simply not effective (for
whatever indication it was prescribed, which may not even be the reason you are
now recommending it) or was it stopped because of some unwanted effect? And was
the unwanted effect an allergic response, idiosyncratic response, an
anticipated side effect, or simply a dose-related side effect. It’s very
important to have details available about the reasons for discontinuation.
Also, as we noted above, medications are often discontinued at times when a
physician or other prescriber may not have access to the EHR or e-prescribing
system. Often they get a phone call from a patient and
tell them over the phone to stop the medication and then forget to record that
in the patient record.
These examples highlight the continuing struggles we have in
optimizing medication reconciliation. The need to do medication reconciliation
at every office, clinic, hospital, or pharmacy visit is obvious. While we need
to rely on technology vendors and HIE/RHIO’s to come up with some better
electronic and interoperability solutions, you also need to look at your own
practice. How do you update your patients’ medication lists after you do that
over-the-phone medication discontinuation? How do you let the pharmacy know you
have stopped a medication? How do you find out if your patient is still being
dispensed a discontinued medication? How do you find out that another physician
has discontinued a medication on one of your patients? And how do you recognize
that the medication you’ve discontinued may have had a drug-drug interaction
with another medication (the dose of which you may now need to adjust)? Lots of
questions. Still no easy answers.
References:
Allen AS, Sequist TD. Pharmacy
dispensing of electronically discontinued medications. Ann Intern Med. 2012; 157(10):700e705
Copi EJ, Kelley LR, Fisher KK.
Evaluation of the frequency of dispensing electronically discontinued
medications and associated outcomes. J Am Pharm Assoc 2018; 58(suppl 4):
S46-S50
https://www.japha.org/article/S1544-3191(18)30186-9/fulltext
Tong EY, Kowalski M, Yip GS, Dooley MJ. Impact of drug
interactions when medications are stopped: the often
forgotten risks. Med J Aust 2014; 200 (6): 345-346
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