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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.
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:
- 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.
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”
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
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
https://humanfactors.jmir.org/2021/4/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
http://europepmc.org/article/MED/29016973
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
https://bmchealthservres.biomedcentral.com/articles/10.1186/s12913-017-2704-3
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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