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Dr. Gaunt is a medication safety analyst and the editor of ISMP Medication Safety Alert! Community/Ambulatory Care Edition.
Ambulatory e-Rx Requires Patient’s Check
A girl was recently taken to a doctor by her parents for evaluation of a skin rash. The doctor prescribed a topical corticosteroid, using a handheld device to place the order electronically. He had asked the couple which pharmacy they’d like to use, which seemed very efficient, except for one issue: the doctor never told the family exactly which drug he was prescribing. He just instructed the parents to pick up the medication at their community pharmacy.
This raises an important question when prescriptions are sent electronically to a pharmacy: How will the patient know what they are supposed to receive, if they are not told the prescribed medication, strength, and directions for use, and given a written copy of the information to compare with the dispensed medication?
In this situation, electronic prescribing (e-prescribing) may lead to an unintended weakness in the system if the patient does not know what to expect when he or she picks up prescriptions at the pharmacy. Ideally, with e-prescribing, patients should receive verbal instructions from the prescriber, be given an opportunity to ask questions, and also be provided with a corresponding voucher listing the prescribed medication, dose, and directions for use. This way, the patient can use the information to check the prescription in the pharmacy by matching the voucher to what he or she actually receives to assure it is correct.
Some e-prescribing systems print out the prescription for the patient to take to the pharmacy. Other systems transmit prescriptions as faxes or send e-prescriptions directly to the pharmacy computer system queue (the ideal for e-prescribing). For the latter 2 situations, prescribers need to simultaneously provide a printed version of the prescription that is properly identified as a duplicate to the patient. This way, patients can know what to expect, read about the drugs, and formulate any questions for their pharmacists before picking up prescriptions, or contact their physicians if they have concerns about taking the medications. Of course, anytime a medication is ordered, the prescriber should provide education to the patient regarding the name, purpose, use, dose, and administration of the medication.
Picking the Wrong Metoprolol
Since the introduction of generic forms of metoprolol succinate, pharmacies have been receiving prescriptions that do not clearly indicate which formulation, succinate or tartrate, a prescriber intends for the patient. This includes e-prescriptions. The risk of a selection error is increased due to name similarities and overlapping dosage strengths.
A pharmacist recently reported that his pharmacy has received several e-prescriptions for the wrong formulation. It appears that most of the errors have occurred when requests for refills of metoprolol succinate have been answered with prescriptions for metoprolol tartrate.
To reduce the risk of mix-ups, make all staff aware of the possibility of confusing these products and incorporate safeguards in your processes for handling these prescriptions. Prescribers should request e-prescribing vendors to include alerts such as short-acting or long-acting for the 2 salts. These same alerts can be incorporated into the pharmacy system. Pharmacy benefit managers also should have a check system in place when adjudicating refill prescriptions.
Be sure patients understand that various dosage forms of metoprolol are available and help them understand which one has been prescribed for them. The pharmacy that reported these events now double-checks the medication profiles of all patients receiving prescriptions for either metoprolol tartrate or metoprolol succinate.
A review of the patient’s profile for current and past medications is a key safety strategy when prescribing and dispensing all drugs, not just metoprolol. Total reliance on softwarechecking may not be adequate to prevent these errors. Subscribe to Newsletter Pharmacy Times and the Institute for Safe Medication Practices (ISMP) would like to make community pharmacy practitioners aware of a publication that is available.
The ISMP Medication Safety Alert! Community/ Ambulatory Care Edition is a monthly compilation of medication-related incidents, error-prevention recommendations, news, and editorial content designed to inform and alert community pharmacy practitioners to potentially hazardous situations that may affect patient safety. Individual subscription prices are $52 per year for 12 monthly issues. Discounts are available for organizations with multiple pharmacy sites. This newsletter is delivered electronically. For more information, send an e‑mail message to community@ismp. org, or contact ISMP at 215-947-7797.