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Original Research |

Pharmacy Dispensing of Electronically Discontinued Medications

Adrienne S. Allen, MD, MPH; and Thomas D. Sequist, MD, MPH
[+] Article and Author Information

From North Shore Physicians Group, Danvers, and Brigham and Women's Hospital, Harvard Medical School, and Harvard Vanguard Medical Associates, Boston, Massachusetts.

Grant Support: Dr. Allen was funded by a National Institutes of Health Institutional National Research Service Award (T32HP10251-02).

Potential Conflicts of Interest: Disclosures can be viewed at www.acponline.org/authors/icmje/ConflictOfInterestForms.do?msNum=M12-1182.

Reproducible Research Statement: Study protocol and statistical code: Available from Dr. Allen (e-mail, aallen0@partners.org). Data set: Not available.

Requests for Single Reprints: Adrienne S. Allen, MD, MPH, North Shore Physicians Group, 104 Endicott Street, Suite 104, Danvers, MA 01923; e-mail, aallen0@partners.org.

Current Author Addresses: Dr. Allen: North Shore Physicians Group, 104 Endicott Street, Suite 104, Danvers, MA 01923.

Dr. Sequist: Division of General Medicine, Brigham and Women's Hospital, 1620 Tremont Street, Boston, MA 02120.

Author Contributions: Conception and design: A.S. Allen, T.D. Sequist.

Analysis and interpretation of the data: A.S. Allen, T.D. Sequist.

Drafting of the article: A.S. Allen, T.D. Sequist.

Critical revision of the article for important intellectual content: A.S. Allen, T.D. Sequist.

Final approval of the article: T.D. Sequist.

Statistical expertise: T.D. Sequist.

Collection and assembly of data: A.S. Allen, T.D. Sequist.


Ann Intern Med. 2012;157(10):700-705. doi:10.7326/0003-4819-157-10-201211200-00006
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Background: Most physician offices do not transmit orders for medication discontinuation to the pharmacy, creating the potential for errors in dispensing of previously prescribed medications. Electronic health records offer the potential to assess this patient safety concern.

Objective: To assess the frequency of and potential patient harm associated with pharmacy dispensing of discontinued medications in the ambulatory setting.

Design: Retrospective cohort study.

Setting: Multispecialty group practice in eastern Massachusetts using an electronic health record.

Patients: 30 406 adult patients with an electronic discontinuation order for antihypertensive, antiplatelet, anticoagulant, oral hypoglycemic, and statin medications between November 2008 and October 2009.

Measurements: Dispensing of discontinued medications within 12 months and associated potential patient harm.

Results: Among 83 902 targeted medications that were electronically discontinued, 1218 (1.5% [95% CI, 1.4% to 1.5%]) were subsequently dispensed by the pharmacy a mean of 1.0 (SD, 0.3) time during the 12-month follow-up. Among the top 10 most frequently electronically discontinued medications, the rate of subsequent dispensing by a pharmacy ranged from 0.9% for metformin to 2.5% for metoprolol. Manual chart review of 416 medication-dispensing events that were predefined as high risk according to an automated algorithm identified potential harm in 50 (12%) cases, including clinical reactions (n = 18), laboratory abnormalities (n = 17), duplicated medication classes dispensed (n = 8), and potential allergic reactions (n = 7).

Limitation: Information on pharmacy dispensing was available for only 52% of medication orders.

Conclusion: The dispensing of discontinued medications represents an important ambulatory patient safety concern. Electronic health records should be used to facilitate better communication between providers and pharmacies and improve medication safety.

Primary Funding Source: National Institutes of Health.

Figures

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Figure.

Identification of reasons for electronic discontinuation of medications detected by using manual chart review.

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Dispensing of Electronically Discontinued Medications
Posted on November 29, 2012
James A. Villier, M.D. F.A.C.P.
Randolph Internal Medicine, Charlotte NC
Conflict of Interest: None Declared
In almost 35 years of medical practice, I had never considered it my responsibility to notify patients’ pharmacies of medication discontinuances. As a user of a robust EMR system for over 5 years, I have become more aware of the problems that electronic prescribing has caused with inappropriate refilling of prescription medications, as pointed out in the recent investigation by researchers Allen and Sequist in the November 20, 2012 edition of the Annals.While notification of patient pharmacies of changing medication profiles would be desirable, the reality of dispensing practices makes this nearly unfeasible. Much of the problem is created by the pharmacies’ own practices of attempting to automate the process of refilling medications.For most of my practice years, prescription refills were made at the time of a patient visit whereby reconciliation was an inherent process. As refills became more often requested via patient-initiated calls (or in some cases made through pharmacies) to the office, that process fell upon the physician to delegate much of that responsibility to trained staff, but only with the final approval of the physician after reviewing the chart. My sense of the past is that dispensing errors were far less than may exist today.With the advent of fax communication, pharmacies began initiating refill requests with forms ready for check-offs, ready for physician signatures, thereby tempting the short-circuiting of the reconciliation process. That appears to have begun the process of automation of refills without patient initiation of the process, thus beginning the problem we have today with refilling of discontinued or changed medications. While such automation would seem to serve the patient with convenience as well as insuring uninterrupted adherence to a prescribed regimen, that escalation of direct pharmacy intervention was self-serving to maintaining a steady generation of prescription production to the financial benefits of pharmacies.The complexity of prescribing medications and treating medical conditions results in ever-increasing requirements for physician oversight of medication management. Dosing changes and medication substitutions are more frequent, the number of medications required to treat patient conditions are increasing as those conditions also increase. This results in more frequent changing of medication profiles which has been facilitated with the use of the EMR and electronic prescribing.Concurrent with that, however, has been changing patient preferences for pharmacies as they seek better service or lower costs. The advent of the mandated pharmacy benefit managers, (Medco, Caremark and others), has created further players in the dispensing process, hindering any attempt at notifying dispensing pharmacies of changes. Although the EMR logs the dispensing pharmacy for any given medication prescription, patient preferences change almost as often as the prescriptions themselves making it nearly impossible to design a system of notification to any pharmacy which may have dispensed a prior medication.Now the process is made even worse with electronically-received pharmacy-initiated requests for refills. Automated refill requests are commonly received for medications that have been changed. Duplicate refill requests are received for medications previously refilled for extended dates, oftentimes sent to the same pharmacy which doesn’t delete the older prescription.Automated pharmacy refill requests received by our system have the order sentencing changed to terminology not as originally prescribed and written by physicians. Additionally, such requests are automated to “complete” the original order as exists in the electronic record. As a result, I now routinely reject such automated requests from pharmacies and send refills directly from the EMR with my original sentencing terminology. Such physician interaction is time-consuming with as many as 30 or more requests daily, each requiring physician verification.Physicians shouldn’t suffer the consequences of such attempts at automation by pharmacies, having to make corrections in order to prevent dispensing errors brought on by the pharmacies themselves. The e-prescribing networks (e.g. Surescripts) largely responsible for this mess should be required to develop a solution. EMR software should be re-designed to send medication deletions/ changes through the e-prescribing network to the original dispensing pharmacy. The pharmacy system should be required to delete older prescriptions for the same medication when continuing refills are received. The practice of automated refill requests initiated by pharmacies and not requested by patients should be abolished. Physician terminology for order sentencing should not be altered by the dispensing pharmacy. Any refill request from pharmacies sent back to physicians’ offices should have the original physicians’ order terminology.
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