Patient Safety Tip of the Week
May 30, 2017
Errors in Pre-Populated Medication Lists
When we did our first electronic medical record
implementation over 10 years ago we were excited. We thought we’d have the
medication reconciliation problem solved. We had vendors lined up who had
medication fill data from the insurers and third party pharmaceutical middlemen
to add to data from our own hospital and clinic records. We thought all that
data would give us not only accurate current medication lists but also tell us
a lot about patient compliance/adherence with their medications. Boy, were we
wrong!
We found there were significant gaps in the data. Drugs
provided as free samples in physicians’ offices were not on the list and any
drug a patient might have paid for out-of-pocket was not on the list. Drugs
provided as part of clinical trials were not included. And OTC drugs, including
important ones like aspirin, were not on the lists. Moreover, we often saw
drugs on the lists that our patients were not taking. Drugs that had been
discontinued since last dispensed remained on the list (see our March 2017 What's New in the Patient Safety World column “Yes!
Another Voice for Medication e-Discontinuation!” regarding the need for an
electronic way to discontinue medications). In some cases there were simply
errors in the data. We even occasionally saw instances where a patient was
getting a drug that was actually intended for their (uninsured) family member
or friend.
We also saw cases where doses of medications were erroneous.
For example, some patients were utilizing pill-splitting so they were really
only taking half the dose that appeared on the pre-populated forms. In other
cases, the dose had been adjusted since the last dispensed amount appearing on
the forms.
So there were several dangers in using such pre-populated
lists. An important medication might be omitted when a patient was admitted to
a hospital. Or a medication that had been discontinued or never intended to be
used might be inadvertently started on admission to a hospital. In other cases,
incorrect doses were given.
Now, a formal study on the errors on such pre-populated
medication lists expands upon our experience. Canadian researchers (Stockton 2017) analyzed
data on hospitalized patients where the “best possible medication history”
lists were pre-populated with data from a Canadian medication dispensing system
and records of drug dispensing from other outpatient dispensing facilities.
They found that 47% of the 151 patients in their study were exposed to
medication errors on admission. Of 112 medication errors identified, 85 (75.9%)
were categorized as unexplained medication discrepancies. The majority of these
were inappropriate discontinuations (38%) and omissions (28%). But they also
found 24% were errors of “commission”, including 10 cases of continuation of
medications that were contraindicated and 17 cases where previously
discontinued medications were reordered. 15% of the medication discrepancies
were deemed to have the potential to cause moderate harm and 1 case had the
potential to cause serious harm. Errors of commission were especially likely to
potentially cause harm. Analyzing multiple variables they found taking 8 or
more medications and presence of cognitive impairment were factors associated
with unexplained medication discrepancies.
The authors felt that there may be an overreliance on
dispensing data by prescribers, leading to less rigorous attempts to take
careful medication histories and otherwise verify the lists. They also note
that it is quite easy to click boxes on the prepopulated forms.
Obviously, we are not surprised at the findings in the
Stockton study. It clearly points out the pre-populating medication lists is
fraught with dangers. That doesn’t mean pre-population should never be used.
But it emphasizes the need for careful verification, using multiple sources, of
any and all medications during medication reconciliation.
Also, that one unexpected issue we encountered (medications
intended for someone other than the patient) puts the physician in a very
uncomfortable position of wanting to help his/her patient but having uncovered
an instance of healthcare fraud.
References:
Stockton KR, Wickham ME, Lai S, et al. Incidence of
clinically relevant medication errors in the era of electronically prepopulated
medication reconciliation forms: a retrospective chart review. CMAJ Open 2017; 5(2):
E345-E353 May 5, 2017
http://cmajopen.ca/content/5/2/E345.full
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