Alerting pharmacies about cancelled medications can prevent errors
Failing to inform pharmacies that a prescription medication has been discontinued could lead to significant safety issues, according to new data presented at ACC Quality Summit Virtual.
In the study, researchers investigated why pharmacy communication on cancelled drugs was not always occurring and looked for new ways for pharmacy staff to find out about canceled medications.
"Currently there is no ideal way to notify a pharmacy that a clinician has discontinued medication for a patient, often leading to a discontinued medication or incorrect dose to be refilled and causing confusion for the patient," co-author Jeffrey A. Goss, FNP-c, MSN, a specialist at Intermountain Healthcare in Murray, Utah, said in a news release from the American College of Cardiology. "Patients are at risk for taking a medication that is no longer indicated or at the wrong dose, which has important medication safety indications."
The study's authors learned that Intermountain Healthcare had experienced several safety events that involved discontinued medications that were accidentally taken by patients. They tried to fix the problem by having clinical staff call the pharmacy informing them of medication changes and requesting that the medication be removed from the patient's profile.
In addition, clinicians were also asked to document medication changes in the "comments" box in the electronic prescription to alert the pharmacy about any changes.
However, this was not viewed as a reliable method of communication because not all pharmacies see this information.
Hoping to accomplish more of a change, the same researchers had 16 advanced practice providers at the Intermountain Medical Center Advanced Heart Failure/Transplant team activate the CancelRX functionality in their electronic medical record system for 60 days. CancelRX is a function that informs the pharmacy of a discontinued medication the same way it would a new prescription.
The authors found that the functionality was initially turned off because of a high number of associated error messages to clinicians. In addition, it is also contingent on the pharmacy having the same functionality turned on to receive the messages.
During the CancelRX trial, the Intermountain Medical Center Advanced Heart Failure/Transplant team tracked a total of 558 discontinued medications.
They also received 359 error messages and made 148 phone calls to pharmacies.
Overall, 196 potential safety events were prevented using both phone calls and CancelRX during the trial period.
Intermountain Pharmacies, Smiths, Walgreens, Costco, and CVS were among the pharmacies that received error messages during the study.
"Effective communication between the clinician and the pharmacy is paramount to ensuring patients only receive medications they require," co-author Steven Metz, PharmD, BCPS, also of Intermountain Healthcare, said in the same news release. "In addition to the safety implications, this will also reduce the likelihood of a patient purchasing a discontinued prescription, resulting in cost savings for patients and insurance payers."
The study authors recommend health systems review how their electronic medical record system interfaces with their community pharmacies to minimize the potential for an error to occur.
More information about ACC Quality Summit Virtual is available on the American College of Cardiology’s website. The meeting runs through Oct. 1.