Pharmacies May Continue to Dispense Medications Even After Prescribers Discontinue Them

When a prescriber writes a medication order, it is transmitted to the pharmacy—either electronically or via human transport. However, when the prescriber discontinues a medication, communication with the pharmacy isn’t so seamless. The pharmacy may continue to dispense the drug, possibly endangering the patient’s health. A recent study suggests that this kind of error may occur with more than 1 in 100 discontinued medications.

One study published in the Annals of Internal Medicine assessed how frequently this error occurs in ambulatory settings because most physician offices do not transmit orders to pharmacies when medications are discontinued. Researchers reviewed the electronic health records of more than 30,000 adults who had a discontinuation order either for an antihypertensive, antiplatelet, anticoagulant, oral hypoglycemic, or statin medication. They studied these medications because they are prescribed for long-term use and can cause significant harm when used incorrectly.

The study also evaluated possible patient harm resulting from discontinued medications, defining harm as a new laboratory abnormality, a clinical reaction, dispensing another medication from a similar drug class, or dispensing a medication for a patient with a documented allergy to the medication.

Study Findings

The study determined that, although physicians had electronically discontinued 83,902 medications for the 30,406 adults in the study, pharmacies continued to dispense 1.5% of the discontinued medications. Among the medications that were incorrectly dispensed, about one third posed a higher risk for adverse effects. Of these, 50 medications were associated with harm. Adverse effects ranged in severity from minor laboratory abnormalities to significant hypotension. The study also found that being a member of the Black race, having Medicaid or Medicare coverage, and having a higher number of current medications on the electronic medication list increased the likelihood that discontinued medications would be dispensed.

Lack of Communication

Although the study was limited by several factors, including the number of drugs reviewed, it clearly identified a problem: Lack of communication between the prescriber and the pharmacy contributed to these medication errors. The good news is that the study raises awareness of the problem and sheds light on several possible solutions.

Technology: Both a Problem and a Solution

Although technology can improve prescribing accuracy, the electronic health record can create a false sense of efficacy and lead some prescribers to assume that, because the prescription process is automated, the pharmacy automatically receives an electronic order when a medication is discontinued. However, the electronic health record can also offer the potential to minimize this type of medication error. Electronic health records clearly portray when medications are discontinued, so discontinuation orders could be electronically transmitted to the retail pharmacy. However, systems capable of this type of communication for ambulatory patients are not yet widely in place.

Another way to prevent these medication errors that does not rely on technology is to manually reconcile medications with patients during each office visit—a process that will likely reveal any use of discontinued medications. Medication reconciliation should include these steps:

  • Ask the patient to bring all the medications he or she currently takes. During each office visit, verbally confirm the medications and dosages with the patient.
  • Obtain a list of the patient’s medications from other sources, such as the patient’s record or an electronic list.
  • Compare the medications the patient takes with the ones listed in the other sources, noting any changes or discrepancies. Be particularly alert for new or discontinued medications, dosage or administration changes, and short-term medications that must be discontinued after a specific time.

Another low-tech method to help reduce errors is to engage patients in their care plan, which includes increasing their awareness of medications by enhancing the patient’s understanding of the prescribed regimen and empowering him or her to spot improperly dispensed medications. Here are some useful methods:

  • Teach the patient about each prescribed medication, including its purpose.
  • Involve the pharmacist, if possible.
  • Instruct the patient to have all prescriptions filled at one pharmacy.
  • Advise the patient to carry an up-to-date list of current medications at all times.
  • Ask about any change in the patient’s insurance, which can lead to a change in providers and result in discontinuity of care and medication errors.
  • Communicate with healthcare providers, as needed. Also facilitate communication among the patient’s providers, such as the inpatient physician and primary care physician, if needed.

Lastly, consider integrating electronic tools designed for medication management. For example, ExitCare® offers ExitMeds®, an electronic tool that works with the electronic health record and enhances medication reconciliation. ExitMeds® offers a suite of patient education and medication management products designed to promote patient engagement, compliance, and comprehension that includes a medication summary to clearly communicate patient medication status as either “existing,” “new,” or “modified” medications. All of a patient’s medications can be reconciled on one screen. This tool also generates a patient education sheet, listing current drugs and any drugs that the patient should stop taking.

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