View as “PDF version

Patient Safety Tip of the Week

March 1, 2022

Including the Indication on Prescriptions



In the early 1990’s, when we first began 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”.


Why is it important? 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 accidently 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 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.


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).


A recent review of the literature (Mercer 2021) found that including the reason for use on a prescription can help the pharmacist catch more errors, reduce the need to contact prescribers, support patient counseling, impact communication, and improve patient safety. The authors also noted that concerns about workflow, time required to enter the indication, and privacy were impediments to adding reason for use information on the prescriptions. However, they note that only 1 paper (Garada 2017) examined privacy concerns and concluded that while pharmacists and physicians were concerned about privacy, patients were not generally concerned with the privacy implications of documenting reason for use on a prescription. And one could certainly make the argument that the slight additional time required to enter the indication would be offset by the time spent on clarification phone calls with pharmacists.


Three of the studies they reviewed also noted that inclusion of reason for use is important in pharmacists’ providing accurate patient counseling. Without knowledge of the indication for a medication, a pharmacist can counsel a patient about how to take a medication and what potential side effects might occur but would be unable to discuss what beneficial effects to look for.


Mercer et al. point out that, despite the potential benefits of including indication for medication, the reason for use is not identified as a core measure included in the electronic health record in most hospital systems (Adler-Milstein 2017). Since almost all prescribing in the US today is done electronically, there is no reason for failure to include a field for the indication in CPOE and ePrescribing systems.


There is some debate as to what should be input into an “indication” field. Should it be a diagnosis? Some physicians have suggested it should be in plain language rather than medical terminology (Garada 2017). Our own recommendation is perhaps a hybrid approach. CPOE and ePrescribing systems should  have drop-down lists of common reasons for ordering each medication but would also need an “other” category for entering free text if the indication is something other than the common ones presented. While we 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. All CPOE and ePrescribing systems also need to have mechanisms for updating the indications in the drop-down lists when indications may change.


The concept of using plain language for patients is a good one but that would be more appropriate for inputting into a “sig:” (patient directions) field that would be applied to the label on the medication dispensed to the patient.


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. It may be important to know whether a medication was discontinued because of:


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.


Not only do we lack systems for documenting reasons for discontinuation, we also do a poor job in communicating when 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



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








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



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



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



Mercer K, Carter C, Burns C, Tennant R, Guirguis L, Grindrod K. Including the Reason for Use on Prescriptions Sent to Pharmacists: Scoping Review. JMIR Hum Factors 2021; 8(4): e22325



Adler-Milstein J, Holmgren A, Kralovec P, Worzala C, Searcy T, Patel V. Electronic health record adoption in US hospitals: the emergence of a digital "advanced use" divide. J Am Med Inform Assoc 2017; 24(6): 1142-1148



Garada M, McLachlan AJ, Schiff GD, Lehnbom EC. What do Australian consumers, pharmacists and prescribers think about documenting indications on prescriptions and dispensed medicines labels?: A qualitative study. BMC Health Serv Res 2017; 17(1): 734



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






Print “PDF version












Tip of the Week Archive


What’s New in the Patient Safety World Archive