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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.


In addition to transmission of the reason for discontinuation, Pitts et al. suggest strategies 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






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



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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