Inappropriate Prescribing Practices: The Challenge and Opportunity for Patient Safety

Abstract

Adverse clinical events related to inappropriate prescribing practices are an important threat to patient safety. Avoidance of inappropriate prescribing in community settings, where the majority of prescriptions are written, offers a major area of opportunity to improve quality of care and outcomes. Electronic medication order entry systems, with automated clinical risk screening and online alerting capabilities, appear as particularly promising enabling tools in such settings. The Medical Office of the Twenty First Century (MOXXI-III) research group is currently utilizing such a system that integrates identification of dosing errors, adverse drug interactions, drug-disease and allergy contraindications and potential toxicity or contraindications based on patient age. This paper characterizes the spectrum of alerts in an urban community of care involving 28 physicians and 32 pharmacies. Over a consecutive nine-month period, alerts were generated in 29% of 22,419 prescriptions, resulting in revised prescriptions in 14% of the alert cases. Drug-disease contraindications were the most common driver of alerts, accounting for 41% of the total and resulting in revised prescriptions in 14% of cases. In contrast, potential dosing errors generated only 8% of all alerts, but resulted in revised prescriptions 23% of the time. Overall, online evidence-based screening and alerting around prescription of medications in a community setting demands confirmation in prescribers' clinical decision making in almost one-third of prescriptions and leads to changed decisions in up to onequarter of some prescribing categories. Its ultimate determination of clinical relevance to patient safety may, however, have to await more detailed examination of physician response to alerts and patient outcomes as a primary measure of utility.Patient safety is an increasingly recognized challenge and opportunity for stakeholders in improving health care delivery. It involves many issues, including delayed diagnosis and treatment, as well as inappropriate undertreatment and overtreatment. The common denominators, however, are that care and outcomes could be better, and there is a role for patients, providers and policy makers in making improvements.

Nature and frequency of prescription modifications: An evaluation from the community pharmacy

“…Wrong patient data, double medication, interaction with other medicines, contraindication pregnancy or children, and contraindication allergy were significantly higher (92.4%). The prescribing error incidence is comparable to those reported in other studies (Taylor, 2005). In an Irelandbased study by Sayers et al, (2009) from a total of 3,948 prescriptions, 491 (12.4%) contained one or more errors, and from a total of 8,686 drug items, 546 (6.2%) contained one or more errors.…”

Decrease in use of contraindicated drugs with automated alerts in children

“…Automated alerts were regarded as a potentially promising tool to reduce inappropriate drug use, including age‐related and drug–disease contraindications, and drug–drug interaction . Previous research on similar actions in the USA showed mixed results.…”

Physician experiences transitioning between an older versus newer electronic health record for electronic prescribing

“…Most physicians in this study did not perceive the commercial EHR as better able to decrease prescribing errors even though it had the capability to provide more robust CDS. Although some alerts were perceived as useful, the benefit was often lost because of the high volume of clinically irrelevant alerts [6,[36][37][38]. Alert fatigue has been well documented and may help account for the mixed safety benefits seen among ambulatory e-prescribing systems [2, [6][7][8][9]11,12].…”