Abstract Demonstrates Safety Events Reduced Through Notifying Pharmacies of Discontinued Prescriptions


The study sought to highlight the issues with the correct routing of discontinued medications, which increases the risk of medication safety events.

An abstract presented at the American College of Cardiology Quality Summit Virtual showed that there are several methods that can be used to alert community pharmacy staff about canceled medications, potentially avoiding nearly 200 safety events over 2 months.

The study sought to highlight the issues with the correct routing of discontinued medications, which increases the risk of medication safety events. This issue continues to grow as many prescriptions are sent to pharmacies via electronic health record systems.

"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," said study author Jeffrey A. Goss, FNP-c, MSN, APP director of Heart Failure for Intermountain Healthcare in Murray, Utah, in a press release. "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 team at Intermountain Healthcare attempted temporary fixes, including clinical staff personally calling the pharmacy to alert them of new medication changes and requesting the medication be removed from the patient’s profile. Additionally, clinicians were asked to document medication changes in the “comments” box of a prescription sent electronically to further alert pharmacy staff about medication changes, according to the study.

There were 16 advanced practice providers at the Intermountain Medical Center Advanced Heart Failure/Transplant team over the course of 60 days that used CancelRx to notify the pharmacy of a discontinued medication. Throughout the trial, they tracked a total of 558 discontinued medications, receiving 359 error messages and making 148 phone calls to pharmacies. There were 196 potential safety events avoided using CancelRx and phone calls during the trial, with the 5 pharmacies including Intermountain Pharmacies (210), Smiths (117), Walgreens (38), Costco (25), and CVS (23).

"Effective communication between the clinician and the pharmacy is paramount to ensuring patients only receive medications they require. 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," said study author Steven Metz, PharmD, BCPS, Advanced Clinical Ambulatory Care Pharmacist, Intermountain Healthcare in Murray, Utah, in the press release.

The study authors recommend health systems reviewing how their electronic medical record systems interface with their local pharmacies to stop 1 less area of potential error in patient care.


Notifying Pharmacies of Discontinued Prescriptions Helps Reduce Safety Events. American College of Cardiology. September 29, 2021. Accessed October 1, 2021. https://www.acc.org/about-acc/press-releases/2021/09/29/12/51/notifying-pharmacies-of-discontinued-prescriptions-helps-reduce-safety-events

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