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E-prescribing and medication errors

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E-prescribing and medication errors

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A patient sits with her physician at the conclusion of her examination. He talks to her about a new medication she needs, opens up a file on his computer or smart phone, clicks on a drug and sends the prescription directly to the pharmacy. This is e-prescribing. Is it safe and effective, or are there problems with e-prescribing?

The use of e-prescribing shows dramatic growth. Both the benefits and the drawbacks should be considered. According to the 2009 National Progress Report on e-prescribing which is published by Surescripts, the operator of the largest e-prescription network, electronic prescriptions increased 181% from 2008-2009.

The government is pushing e-prescribing. This number will continue to grow based on the Centers for Medicare and Medicaid Services “voluntary” incentive program. Although it is voluntary now, the program forces physicians to adopt e-prescribing by transitioning from incentive payments to penalties on covered Medicare charges.

E-prescribing should get another boost as the Drug Enforcement Agency interim final regulations that took effect June 1, 2010, will allow for e-prescribing of controlled substances (typically narcotic pain-relievers) in the US. Pharmacies may not begin to receive these orders for another 6-18 months as the software vendors make the updates to computer systems that will allow prescribers to transmit the medication orders, intermediaries to process the prescriptions, and pharmacies to receive them. Furthermore, as the regulatory barriers to controlled substances become more streamlined patients may be more likely to receive prescriptions for them.

Benefits of E-prescribing

E-prescribing can and will benefit quality of care. The following are just some of the ways.

  • Prevents medication prescription errors caused by events such as illegible hand writing, look-alike or sound-alike drugs, drug-drug interactions, incorrect dosing, drug allergy reactions, duplication of drugs, etc. and, thereby, reduces health care and legal costs
  • Eliminates illegible prescriptions
  • Provides for real-time communications between doctors, pharmacies and patients
  • Provides critical drug alerts and patient specific information at the healthcare professionals’ fingertips
  • Provides drug pricing information
  • Provides payer coverage and preferred drug information
  • Creates a complete patient medication history
  • Reduces fraud and crime
  • Increases healthcare professional work efficiency and reduces administrative costs
  • Expedites refills

Drawbacks of E-prescribing

A new technology is not without its drawbacks. Some of the more notable issues with e-prescribing include

  • Accidental data entry errors such as selecting the wrong patient or clicking on the wrong choice in a menu of dosages or selecting conflicting directions of use.
  • Inadvertently divulging protected health information on the internet through inadequate security practices. Hospitals and clinics should be protected with firewalls, use strict computer permission settings, and remain vigilant toward signs of intrusion.
  • Inability to use electronic prescribing when power is out, when the exam room computer has failed, or when providing treatment outside of a standard health care setting.
  • No standardization of current messaging and data structure for software which ultimately can result in inconsistent prescriber and pharmacy workflows.

About the author: Dave Boblenz, PharmD, is a pharmacist with over 14 years experience.

Comments
As is true with any prescription, whether handwritten on a prescription pad or sent electronically to the pharmacy. Errors may be made in the drug selection, dosage and route of administration. The physician, nurse practitioner or physician’s assistant may fail to provide education about side effects or provide sufficient details to provide an informed consent about the risks of the medications.

In one study, doctors agreed to be recorded during patient visits as they prescribed drugs new to those patients. Here is the percent of time the doctors gave people the following critical pieces of information:
Reason for taking the drug: 87%
Name of the drug: 74%
How often to take it: 68%
How much to take each time: 55%
Side effects: 35%
How long to keep taking the drug: 34%

In addition to errors in prescriptions covered by a previous blog post, consider errors in filling e-prescriptions. The pharmacist or technician may have pulled the wrong drug off the shelf or provided the wrong dose. While e-prescribing reduces errors, it does not eliminate them.

References
Use of E-Prescribing Grows Dramatically
Physician Quality Reporting Initiative
Elizabeth Bewley, author of Killer Cure, Dog Ear Publishing, cites the study by Derjung, T., Heritage, J. Paterninti, D. et al, “Physician communication when prescribing new medications”, Archives of Internal Medicine 25 September 2006

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9 Responses to “E-prescribing and medication errors”

  1. e- prescribing is a formidable piece of technology (the latest in process management) but only when it is used correctly with proper judgement and safety constraints. Primarily, e-prescribing is intended ONLY for the prescriber to perform this task himself/herself. It is not intended for the prescriber (MD, PA or NP) to tell verbally the nurse and the nurse to tell the nurse assistant, and the nurse assistant to delegate to the office receptionist to input the e-prescribe data and trasmit the data to the pharmacy. You do not handle e-prescribing the same way as you workflow paper data. If the e-prescribing is left for the office receptionist to do, then the system used is the old paper system workflow with a touch of e-prescribing at the end of the process. When the office receptionist enters the e-prescription, she/he does not know medicines, and does not know therapies, and does not have a license to know that, and should not be allowed to enter e-prescriber data, data intended exclusively for the physician (or nurse practitioner or physician assistant) to enter. And this is the cause of e-prescribing errors. Non-responsible use of the technology. IN SUMMARY: e-prescribe is intended for the prescriber only to perform this function.

    Most errors are made at the drug selection phase, dosage and route of administration, and in many cases in frequency of administration. Patient selection errors is also very common.

  2. e- prescribing is a formidable piece of technology (the latest in process management) but only when it is used correctly with proper judgement and safety constraints. Primarily, e-prescribing is intended ONLY for the prescriber to perform this task himself/herself. It is not intended for the prescriber (MD, PA or NP) to tell verbally the nurse and the nurse to tell the nurse assistant, and the nurse assistant to delegate to the office receptionist to input the e-prescribe data and trasmit the data to the pharmacy. You do not handle e-prescribing the same way as you workflow paper data. If the e-prescribing is left for the office receptionist to do, then the system used is the old paper system workflow with a touch of e-prescribing at the end of the process. When the office receptionist enters the e-prescription, she/he does not know medicines, and does not know therapies, and does not have a license to know that, and should not be allowed to enter e-prescriber data, data intended exclusively for the physician (or nurse practitioner or physician assistant) to enter. And this is the cause of e-prescribing errors. Non-responsible use of the technology. IN SUMMARY: e-prescribe is intended for the prescriber only to perform this function.

    Most errors are made at the drug selection phase, dosage and route of administration, and in many cases in frequency of administration. Patient selection errors is also very common.

  3. e- prescribing is a formidable piece of technology (the latest in process management) but only when it is used correctly with proper judgement and safety constraints. Primarily, e-prescribing is intended ONLY for the prescriber to perform this task himself/herself. It is not intended for the prescriber (MD, PA or NP) to tell verbally the nurse and the nurse to tell the nurse assistant, and the nurse assistant to delegate to the office receptionist to input the e-prescribe data and trasmit the data to the pharmacy. You do not handle e-prescribing the same way as you workflow paper data. If the e-prescribing is left for the office receptionist to do, then the system used is the old paper system workflow with a touch of e-prescribing at the end of the process. When the office receptionist enters the e-prescription, she/he does not know medicines, and does not know therapies, and does not have a license to know that, and should not be allowed to enter e-prescriber data, data intended exclusively for the physician (or nurse practitioner or physician assistant) to enter. And this is the cause of e-prescribing errors. Non-responsible use of the technology. IN SUMMARY: e-prescribe is intended for the prescriber only to perform this function.

    Most errors are made at the drug selection phase, dosage and route of administration, and in many cases in frequency of administration. Patient selection errors is also very common.

  4. Lets visualize a real scenario. SCENARIO ONE: the e-prescription is entered correctly by the prescriber herself/himself and is transmitted to the pharmacy. The pharmacy uses in this case a central pharmacy operation (central fill) based system. The electronic data ( e-prescribed) enters the Central Pharmacy system in seconds, and it enters the intricate workflow and management process system of the Central Utility of the central pharmacy operation. At the Central Utility, the e-prescription enters the doctor-patient verification phase (in most cases this process is bypassed, due to the fact that the it was e-prescribed and Doctor-Patient verification phase is intended mostly to detect human errors in scanning in cases of selecting incorrect patients or incorrect doctors. At Central Utility, Central Pharmacy Operations, the e-prescription enters the Data Entry phase that is performed by a technician. The Data Entry technician has handling times metrics assigned (average handling time of 35 seconds) to interpret the data. In some cases the interpretation is left to the computer to read, since the system could automatically read some e-prescribe data.( i.e. Z-PACK, as directed #6 tablets). However, if there is an error, the Data Entry tehnician of Central Utility does not know this ( is not a licensed pharmacist….). After data entry (45 seconds average as given handling time metrics) the e-prescribe enters the Pharmacist Data Verification that is performed by a licensed pharmacist. This process is only assigned 13 seconds (for average handling time metrics). Here, the pharmacist reads, approve, and or perform changes or re-enters the data if incorrect, in just 13 seconds. From this phase, the Central Utility process management system sends the Clinical Data Verification Pharmacist, the link of the e-prescription (already verified) and check automatic Drug Utilization Review. Once the Clinical Data is approved ( 8 seconds handling time metrics and in most cases 5 seconds) the e-prescription is ready electronically to reach the store (pharmacy) location where the pharmacist prints the label and dispenses the medication. Scenario one was a perfectly entered e-prescribed Rx, performed in seconds by the doctors office, and performed in just few minutes by a central pharmacy operations system at the local pharmacy. SCENARIO TWO: This is an scenario where there was an error from the prescriber when sending the electronic data. With restricted handling times (45 seconds) for the Data Entry Technician at Central Utility, the incorrect e-prescribe data passes to Data Verification where a licensed pharmacist has 13 seconds (as an average handling time) to approve, reject, and or make changes, and or re-enter the data. Also Central Utility has 8 seconds to interpret DUR, and clinical interaction, that at this point will have red flags, and level one interaction and or over dose warnings, etc… if the system automatically was able to interpret the dose error as error per se.

    This is how an e-prescribe Rx order enters the intricate prescription processing system of todays central pharmacy operation super pharmacy dispensers. There is no room for errors. The Rx that is e-prescribe should be performed by the prescriber, and verified by the prescriber before transmision, since once it enters the pharmacy electronic network, there is no room for errors with their limited handling time assigned to them in each phase of prescription verification and approval process.

    The pharmacy central operation processes and workflow (central fill) indicated here are performed since 2008 in Florida, Nevada, and Arizona. This system applies also for non-e prescribe Rx, and is a total paperless, Electronic Health Record pharmacy system. Maintenance medications are processed the same way and channeled to an industrial size dispensing facility (central fill facility), located in the same building where Central Operations is located. The maintenance Rxs are then dispensed and physically transported in trucks (twice a day) and distributed to the corresponding local pharmacies. At the store location level, the pharmacist do dispensing but only the waiting patients or stat orders, however, the verification processes are conducted at the central pharmacy operations with electronic technology.

  5. Lets visualize a real scenario. SCENARIO ONE: the e-prescription is entered correctly by the prescriber herself/himself and is transmitted to the pharmacy. The pharmacy uses in this case a central pharmacy operation (central fill) based system. The electronic data ( e-prescribed) enters the Central Pharmacy system in seconds, and it enters the intricate workflow and management process system of the Central Utility of the central pharmacy operation. At the Central Utility, the e-prescription enters the doctor-patient verification phase (in most cases this process is bypassed, due to the fact that the it was e-prescribed and Doctor-Patient verification phase is intended mostly to detect human errors in scanning in cases of selecting incorrect patients or incorrect doctors. At Central Utility, Central Pharmacy Operations, the e-prescription enters the Data Entry phase that is performed by a technician. The Data Entry technician has handling times metrics assigned (average handling time of 35 seconds) to interpret the data. In some cases the interpretation is left to the computer to read, since the system could automatically read some e-prescribe data.( i.e. Z-PACK, as directed #6 tablets). However, if there is an error, the Data Entry tehnician of Central Utility does not know this ( is not a licensed pharmacist….). After data entry (45 seconds average as given handling time metrics) the e-prescribe enters the Pharmacist Data Verification that is performed by a licensed pharmacist. This process is only assigned 13 seconds (for average handling time metrics). Here, the pharmacist reads, approve, and or perform changes or re-enters the data if incorrect, in just 13 seconds. From this phase, the Central Utility process management system sends the Clinical Data Verification Pharmacist, the link of the e-prescription (already verified) and check automatic Drug Utilization Review. Once the Clinical Data is approved ( 8 seconds handling time metrics and in most cases 5 seconds) the e-prescription is ready electronically to reach the store (pharmacy) location where the pharmacist prints the label and dispenses the medication. Scenario one was a perfectly entered e-prescribed Rx, performed in seconds by the doctors office, and performed in just few minutes by a central pharmacy operations system at the local pharmacy. SCENARIO TWO: This is an scenario where there was an error from the prescriber when sending the electronic data. With restricted handling times (45 seconds) for the Data Entry Technician at Central Utility, the incorrect e-prescribe data passes to Data Verification where a licensed pharmacist has 13 seconds (as an average handling time) to approve, reject, and or make changes, and or re-enter the data. Also Central Utility has 8 seconds to interpret DUR, and clinical interaction, that at this point will have red flags, and level one interaction and or over dose warnings, etc… if the system automatically was able to interpret the dose error as error per se.

    This is how an e-prescribe Rx order enters the intricate prescription processing system of todays central pharmacy operation super pharmacy dispensers. There is no room for errors. The Rx that is e-prescribe should be performed by the prescriber, and verified by the prescriber before transmision, since once it enters the pharmacy electronic network, there is no room for errors with their limited handling time assigned to them in each phase of prescription verification and approval process.

    The pharmacy central operation processes and workflow (central fill) indicated here are performed since 2008 in Florida, Nevada, and Arizona. This system applies also for non-e prescribe Rx, and is a total paperless, Electronic Health Record pharmacy system. Maintenance medications are processed the same way and channeled to an industrial size dispensing facility (central fill facility), located in the same building where Central Operations is located. The maintenance Rxs are then dispensed and physically transported in trucks (twice a day) and distributed to the corresponding local pharmacies. At the store location level, the pharmacist do dispensing but only the waiting patients or stat orders, however, the verification processes are conducted at the central pharmacy operations with electronic technology.

  6. Responding to E-prescribing and Medication Errors…This writer TOTALLY AGREES with the Response by Oscar Perera, dated March 28, 2011 @ 9:37am. My Father’s Neurologist stated the following: “Just recently, Medicare has required that we digitally send prescriptions to the pharmacy. I used to be able to just write these prescriptions but I cannot do that any longer so I tell my secretary what she needs to send in and it is very possible that she wrote down ‘1/2’ 3 times a day rather that 1 and 1/2 3 times a day.” Needless to say, this error caused harm to my Father. The receiving pharmacy called the Neurologist’s office and ‘someone’ in the office confirmed the ‘1/2’ dosage of Sinemet 3 times a day.

  7. Responding to E-prescribing and Medication Errors…This writer TOTALLY AGREES with the Response by Oscar Perera, dated March 28, 2011 @ 9:37am. My Father’s Neurologist stated the following: “Just recently, Medicare has required that we digitally send prescriptions to the pharmacy. I used to be able to just write these prescriptions but I cannot do that any longer so I tell my secretary what she needs to send in and it is very possible that she wrote down ‘1/2’ 3 times a day rather that 1 and 1/2 3 times a day.” Needless to say, this error caused harm to my Father. The receiving pharmacy called the Neurologist’s office and ‘someone’ in the office confirmed the ‘1/2’ dosage of Sinemet 3 times a day.

  8. As as Pharmacist/Informatics expert with an MBA in Management Information Systems, I am very concerned about medication errors that can “pass the process” undetected if the prescriber is delegating this task (e-prescribing) to personnel without medication prescribing knowledge, or to office personnel unlicensed to prescribe. Delegation of this function (e-prescribe) can not be delegated. The technology of “e-prescribe” was created for the physician (or PA or NP or physician extenders) to electronically by-pass paper technology or “prescription writing” on paper. It was created to create speed in processing functions. Delegating the function of e-prescribe to office personnel “non physician extenders” (such as office receptionists) can cause serious harm to patients, since filters systems are not in place at the prescriber’s level (or sender’s side) and possibly not present either at the receiving side (the pharmacy). The potential error will be technically undetected until dispensed. The margin of error is very large if e-prescribe is delegated by the physician to the non-physicians. Oscar Perera-Montanes is a Clinical Pharmacist Informaticist with MBA in MIS (Management Information Systems) Magna-Cum-Laude from City University of Seattle. His main specialization is EHR and e-prescribe technology. Specialized in Central Operations and Central Utilities electronic operations.

  9. As as Pharmacist/Informatics expert with an MBA in Management Information Systems, I am very concerned about medication errors that can “pass the process” undetected if the prescriber is delegating this task (e-prescribing) to personnel without medication prescribing knowledge, or to office personnel unlicensed to prescribe. Delegation of this function (e-prescribe) can not be delegated. The technology of “e-prescribe” was created for the physician (or PA or NP or physician extenders) to electronically by-pass paper technology or “prescription writing” on paper. It was created to create speed in processing functions. Delegating the function of e-prescribe to office personnel “non physician extenders” (such as office receptionists) can cause serious harm to patients, since filters systems are not in place at the prescriber’s level (or sender’s side) and possibly not present either at the receiving side (the pharmacy). The potential error will be technically undetected until dispensed. The margin of error is very large if e-prescribe is delegated by the physician to the non-physicians. Oscar Perera-Montanes is a Clinical Pharmacist Informaticist with MBA in MIS (Management Information Systems) Magna-Cum-Laude from City University of Seattle. His main specialization is EHR and e-prescribe technology. Specialized in Central Operations and Central Utilities electronic operations.

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