A Prescription For Enhancing Electronic Prescribing Safety

Schiff, Gordon D.; Mirica, Maria; Dhavle, Ajit A.; Galanter, William L.; Lambert, Bruce L.; Wright, Adam

doi:10.1377/hlthaff.2018.0725

Cited by 51 publications

(49 citation statements)

References 30 publications

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“…Second, the lack of a documented indication does not exclude the possibility that there was an undocumented evidenced‐based indication. Prompting clinicians to document an indication for long‐term prescriptions can mitigate this clinical uncertainty while simultaneously improving documentation and the quality of care …”

Section: Discussionmentioning

confidence: 99%

“…Prompting clinicians to document an indication for long-term prescriptions can mitigate this clinical uncertainty while simultaneously improving documentation and the quality of care. 12,24 CONCLUSIONS Older adults are receiving PPI prescriptions at an alarmingly high rate, often against guidelines. This study suggests that potentially minor changes in EHR-based stopping rules and/or targeted physician profiling could have a substantial impact on reducing low-value prescribing.…”

Section: Discussionmentioning

confidence: 99%

See 1 more Smart Citation

Low‐Value Proton Pump Inhibitor Prescriptions Among Older Adults at a Large Academic Health System

Mafi

May

Kahn

et al. 2019

J American Geriatrics Society

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BACKGROUND Older adults are particularly vulnerable to complications from proton pump inhibitor (PPI) drugs. We sought to characterize the prevalence of potentially low‐value PPI prescriptions among older adults to inform a quality improvement (QI) intervention. METHODS We created a cohort of patients, aged 65 years or older, receiving primary care at a large academic health system in 2018. We identified patients currently prescribed any PPI using the electronic health record (EHR) medication list (current defined as September 1, 2018). A geriatrician, a gastroenterologist, a QI expert, and two primary care physicians (PCPs) created multidisciplinary PPI appropriateness criteria based on evidenced‐based guidelines. Supervised by a gastroenterologist and PCP, two internal medicine residents conducted manual chart reviews in a random sample of 399 patients prescribed PPIs. We considered prescriptions potentially low value if they lacked a guideline‐based (1) short‐term indication (gastroesophageal reflux disease [GERD]/peptic ulcer disease/Helicobacter pylori gastritis/dyspepsia) or (2) long‐term (>8 weeks) indication (severe/refractory GERD/erosive esophagitis/Barrett esophagus/esophageal adenocarcinoma/esophageal stricture/high gastrointestinal bleeding risk/Zollinger‐Ellison syndrome). We used the Wilson score method to calculate 95% confidence intervals (CIs) on low‐value PPI prescription prevalence. RESULTS Among 69 352 older adults, 8729 (12.6%) were prescribed a PPI. In the sample of 399 patients prescribed PPIs, 63.9% were female; their mean age was 76.2 years, and they were seen by 169 PCPs. Of the 399 prescriptions, 143 (35.8%; 95% CI = 31.3%‐40.7%) were potentially low value—of which 82% began appropriately (eg, GERD) but then continued long term without a guideline‐based indication. Among 169 PCPs, 32 (18.9%) contributed to 59.2% of potentially low‐value prescriptions. CONCLUSION One in eight older adults were prescribed a PPI, and over one‐third of prescriptions were potentially low‐value. Most often, appropriate short‐term prescriptions became potentially low value because they lacked long‐term indications. With most potentially low‐value prescribing concentrated among a small subset of PCPs, interventions targeting them and/or applying EHR‐based automatic stopping rules may protect older adults from harm. J Am Geriatr Soc 67:2600–2604, 2019

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Section: Discussionmentioning

confidence: 99%

Section: Discussionmentioning

confidence: 99%

Low‐Value Proton Pump Inhibitor Prescriptions Among Older Adults at a Large Academic Health System

Mafi

May

Kahn

et al. 2019

J American Geriatrics Society

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“…Although the recent medical literature emphasizes the fact that the use of computerized prescription systems can decrease the frequency of prescription errors and iatrogenic adverse events and increase the safety of drug prescriptions, we consider that the system correction algorithm can sometimes generate errors ‐ especially in the setting of rare diseases. Indeed, recent literature on medication errors linked to a computerized physician order entry system emphasized the need to understand and then present the causes of these errors . Since PA is a rare inborn error of metabolism with a small number of patients, some treatments are not referenced and not well known—resulting in medication errors.…”

Section: Discussionmentioning

confidence: 99%

“…Indeed, recent literature on medication errors linked to a computerized physician order entry system emphasized the need to understand and then present the causes of these errors. [16][17][18][19][20][21][22] Since PA is a rare inborn error of metabolism with a small number of patients, some treatments are not referenced and not well known-resulting in medication errors. In the present case, the similarity between the two drugs' names ("BHB" vs "GHB," or "3-hydroxybutyrate" vs "4-hydroxybutyrate") increases the risk of confusion and the likelihood of automatically approving a computerized prescription of GHB rather than nonreferenced BHB.…”

Section: Discussionmentioning

confidence: 99%

Administration of gamma‐hydroxybutyrate instead of beta‐hydroxybutyrate to a liver transplant recipient suffering from propionic acidemia and cardiomyopathy: A case report on a medication prescribing error

et al. 2020

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Beta‐hydroxybutyrate (BHB) is a synthetic ketone body used as an adjuvant energy substrate in the treatment of patients with metabolic cardiomyopathy. A medication prescribing error led to the administration of the general anesthetic sodium gamma‐hydroxybutyrate (GHB) instead of sodium BHB in a liver transplant recipient with propionic acidemia and cardiomyopathy, causing acute coma. A 15‐year‐old boy suffering from neonatal propionic acidemia underwent liver transplantation (LT) for metabolic decompensation and cardiomyopathy (treated with cardiotropic drugs and BHB) diagnosed a year previously. The patient had been rapidly extubated after LT, and was recovering well. Eight days after LT, the patient suddenly became comatose. No metabolic, immunological, hypertensive, or infectious complications were apparent. The brain magnetic resonance imaging and electroencephalography results were normal. The coma was soon attributed to a medication prescribing error: administration of GHB instead of BHB on day 8 post‐LT. The patient recovered fully within a few hours of GHB withdrawal. The computerized prescription system had automatically suggested the referenced anesthetic GHB (administered intravenously) instead of the non‐referenced ketone body BHB, triggering coma in our patient. A computerized prescription system generated a medication prescribing error for a rare disease, in which the general anesthetic GHB was mistaken for the nonreferenced energy substrate BHB.

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“…The importance of CancelRx for safe e-prescribing has been recognized by multiple stakeholders. 20,21 Despite the availability of CancelRx in the SCRIPT standard since 2010, adoption has been limited. The Medicare Access and CHIP Reauthorization Act of 2015 (MACRA) required EHRs to include electronic cancellation messaging to pharmacies, but prescribers and pharmacies must also certify their capacity to handle Can-celRx messages.…”

Section: Background and Significancementioning

confidence: 99%

Understanding CancelRx: Results of End-to-End Functional Testing, Proactive Risk Assessment, and Pilot Implementation

et al. 2019

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Background CancelRx allows prescribers to send electronic cancellation messages to pharmacies when medications are discontinued. Little is known about its functionality and impact on clinical workflows. Objectives To understand CancelRx functionality, its potential impact on workflows and medication safety risks, and to develop mitigating strategies for risks introduced by implementation. Methods We conducted direct observations and semi-structured interviews to develop CancelRx use cases and assessed CancelRx in an end-to-end test environment, proactive risk assessment, and pilot implementation from April 16 to July 15, 2018. Results E-cancellations were sent upon discontinuation of e-prescriptions written within the electronic health record (EHR), but not other medications (e.g., printed prescriptions) and could be initiated by nonprescribers. In our proactive risk assessment, CancelRx implementation eliminated five of seven failure modes in outpatient prescribing to Johns Hopkins pharmacies, but introduced new risks, including (1) failure to act if an e-cancellation was not sent or was unsuccessful; (2) failure to cancel all prescriptions for a medication; (3) errors in manual matching; and (4) erroneous medication cancellations. We identified potential mitigation strategies for these risks. During pilot implementation, 92.4% (428/463) of e-cancellations had confirmed approval by the receiving pharmacy, while 4.5% (21/463) were denied, and 3.0% (14/463) had no e-cancellation response. Among e-cancellations received by the pilot pharmacy, 1.7% (7/408) required manual matching by pharmacy staff. Based on performance in testing, 73.4% (340/463) of completed e-cancellations would be expected to generate an in-basket message, including 21 (6.2%) denials and 319/340 (93.8%) approvals with a note from the pharmacy. Conclusion CancelRx is an important functionality with the potential to decrease adverse events due to medication errors. However, changes in implementation in our EHR and pharmacy software and enhancements in the CancelRx standard are needed to maximize safety and usability. Further studies are needed to evaluate the impact of e-cancellation on medication safety.

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A Prescription For Enhancing Electronic Prescribing Safety

Cited by 51 publications

References 30 publications

Low‐Value Proton Pump Inhibitor Prescriptions Among Older Adults at a Large Academic Health System

Low‐Value Proton Pump Inhibitor Prescriptions Among Older Adults at a Large Academic Health System

Administration of gamma‐hydroxybutyrate instead of beta‐hydroxybutyrate to a liver transplant recipient suffering from propionic acidemia and cardiomyopathy: A case report on a medication prescribing error

Understanding CancelRx: Results of End-to-End Functional Testing, Proactive Risk Assessment, and Pilot Implementation

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