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Patient Safety Tip
of the Week
October
11, 2022
Good
Intentions, Unintended Consequences
In
several of our columns we have pointed out that medications we think we have
discontinued, in fact, get continued. One of the biggest gaps in medication
safety is failed discontinuation of medications. 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!
How
does this happen? 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. Our multiple prior columns on this problem are
listed below.
In
our October 2021 What's New in the Patient Safety World column “Tool to Prevent Discontinued Medications from
Being Dispensed” we discussed the CancelRx
tool. CancelRx integrates with clinic EHR and
pharmacy dispensing software and automates the manual process that was
previously delegated to clinic and pharmacy staff. It automatically sends an
electronic notification of a medication discontinuation from a clinic’s EHR to
a pharmacy’s dispensing software. After a clinic prescriber has discontinued a
medication and indicated that the pharmacy should be notified, the order is
processed by a third-party vendor.
In
that column, we highlighted a study from the University of Wisconsin that clearly demonstrated the value of CancelRx in reducing outpatient medication discrepancies by
ensuring communication of medication discontinuation to pharmacies (Watterson
2021).
A new
study (Pitts 2022) demonstrated that CancelRx
implementation did prevent prescriptions from being sold after discontinuation
in the EHR. CancelRx implementation prevented
prescriptions from being sold after discontinuation in the EHR in 42 of 392
instances versus none of 387 instances prior to implementation. However, there
was an unintended consequence - some medications might have been
unintentionally canceled. Medical record review of reordered prescriptions
after CancelRx implementation found that 10 of 49
might have been unintentionally canceled.
Pitts
et al. used medications refilled within 120 days of discontinuation as a
surrogate for unintended cancellation. There are obviously reasons one might
restart a medication, so their estimate of unintended discontinuation likely is
overestimated. Nevertheless, the study does caution us that there may be
unintended consequences of this otherwise very promising tool.
But
the study emphasizes another point we have made over and over – there is not
only a need to document the indication for a drug when we prescribe it, but
also a need to document the reason a drug is being discontinued. In the
Pitts study, intent to discontinue the medication was documented in the EHR in
only 15 of 392 instances (3.8%). A reason for that intent was probably even
more rare.
We’ve
emphasized the importance of providing the reason for discontinuation. There
are many potential reasons for discontinuing a medication, including:
·
Ineffective for this indication
·
Undesirable side effect
·
Allergy
·
Switch to a less expensive drug
·
Drug-drug interaction
·
Formulary change
·
Change in health insurance
Knowing
why a medication was discontinued can have important downstream implications.
For example, let’s say I am considering putting a patient with essential tremor
on propranolol. The patient recalls being on it once before – for migraine. It
would be helpful to know that the propranolol was previously discontinued
because it did not help prevent the migraine rather than being discontinued because
of a side effect.
Or a
medication might have been discontinued due to an interaction with another
medication. Now the patient is no longer on the other medication in that
interaction. The patient could go back on the original medication if it is indicated.
It’s
also especially important when a drug is discontinued and the question of
allergy has been raised. All too often a patient is denied an effective
medication because he/she thought they were allergic to it when, in fact, they
simply had a minor side effect of that medication.
trategies to increase situational
awareness of providers and pharmacy staff, including increased visibility of CancelRx, and clear distinctions between active and expired
prescriptions.
CancelRx appears to be a good tool, but the Pitts study
lets us know it is not infallible. A few tweaks, such as requiring a reason for
discontinuation, should make it even better.
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”
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”
March
1, 2022 “Including
the Indication on Prescriptions”
May
24, 2022 “Requiring
Indication for Antibiotic Prescribing”
References:
Watterson
TL, Stone JA, Brown R, et al. CancelRx: a health IT
tool to reduce medication discrepancies in the outpatient setting, Journal of
the American Medical Informatics Association 2021; 28(7): 1526-1533
https://academic.oup.com/jamia/article-abstract/28/7/1526/6211610?redirectedFrom=fulltext
Pitts
SI, Yang Y, Woodroof T, et al. The Impact of Electronic Communication of
Medication Discontinuation (CancelRx) on Medication
Safety: A Pilot Study. Journal of Patient Safety 2022; 18(6): e934-e937
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