Enhanced communication between the clinician and pharmacy about discontinued or canceled medications potentially averted almost 200 safety events over 60 days, new data suggest.
“As providers, we take advantage of ‘When I send a new prescription in, it routes and the patient fills it because if it didn’t, I would know about it,’ but when a canceled prescription doesn’t cancel off the pharmacy side of things, I think we’re unaware,” study author Jeffrey A. Goss, FNP-c, MSN, a family nurse practitioner at Intermountain Heart Institute, Murray, Utah, told theheart.org | Medscape Cardiology.
As to how often healthcare systems and their providers may be unaware this essential step isn’t taken, he replied: “I don’t know, but my fear is this is a bigger problem than people realize.”
The results were presented virtually at the 2021 American College of Cardiology (ACC) Quality Summit.
Initially, clinic staff — including registered nurses, transplant assistants, a pharmacist and pharmacy tech — tried temporary fixes like personally calling community pharmacies to attempt to weed out medications from the patient’s profile that were no longer indicated, were duplicated, or were documented at the wrong dose. Providers were also asked to document any medication change in the “comments box” of an electronic prescription, but the details weren’t reliably seen by pharmacy teams.
Intermountain’s new electronic health record (EHR) system also had an automated function, CancelRx, to alert community pharmacies of canceled or discontinued medications, just as it would a new prescription, but the function was initially turned off because of a low yield.
“It wasn’t communicating, so when we discontinued a medication, it would send an error message back to the prescribing provider and then their inbox within the EMR would be clogged with these error messages that they didn’t know how to resolve,” Goss said.
It turned out that many of the pharmacies simply hadn’t turned on the CancelRx functionality to receive the messages. Identical refills and prescriptions that were printed at some point and didn’t have a pharmacy to route back to also triggered error messages, he said. The missed communications, however, led to some “concerning symptoms” and in two occasions resulted in hospitalization.
“The one that triggered us taking a harder look at this was a heart failure patient, who was very good about his medications but relied on his pharmacy to fill all his medications and he didn’t double check, and we stopped one of his beta-blockers and switched it to a different beta-blocker,” Goss recounted. “But the pharmacy didn’t get that message and dispensed both beta-blockers to the patient, which he then took, resulting in profound bradycardia and he got hospitalized.”
The case was resolved without further escalation of care, and a feasibility study was launched that turned the CancelRx function back on from April to June of this year for 16 advanced practice providers in the Intermountain Medical Center heart failure/transplant team.
Team members worked electronically in the EHR and in a team chat application to communicate changes and resolve error messages. An algorithm was also created for CancelRx flow that routed error messages received by providers to a pharmacy pool for evaluation and, if needed, a phone call to the pharmacy to update the patient profile, and also sent medication instructions to patients.
Over the 2 months, the team tracked 558 discontinued medications and received 359 (64%) error messages. A total of 148 phone calls were made, averaging 2 minutes and 11 seconds per call (total phone time, 296 minutes).
If CancelRx is turned on at both the pharmacy and healthcare system, “it works seamlessly and over time there would be less need to track and communicate these medication cancelations,” Goss noted during his presentation. But “ultimately, it goes back to patient safety and avoidance of serious safety events.”
In addition to the safety implications, effective communication between the clinician and pharmacy “will also reduce the likelihood of a patient purchasing a discontinued prescription, resulting in cost savings for patients and insurance payers,” study co-author Steven Metz, PharmD, BCPS, advanced clinical ambulatory care pharmacist at Intermountain Healthcare, said in a press release.
The results show no one pharmacy was to blame for the error messages, with the top five “offenders” being Intermountain Pharmacies (210), Smith’s (117), Walgreens (38), Costco (25), and CVS (23).
A deeper dive into why pharmacies didn’t activate the CancelRx functionality is planned but it may be because of a lack of awareness, financial considerations, or software interface, Goss said in an interview.
He noted that when CancelRx first went live, about 60% of messages coming back to providers were error messages. But that number is down now to about 30%, “which is why our bigger push now is to get it turned on system-wide,” something Intermountain Healthcare is currently reviewing.
All healthcare systems should review how their electronic orders interface with outpatient pharmacies to ensure both new and discontinued prescriptions route properly, so that appropriate corrective actions can be taken to reduce real and potential errors between the EHR, local pharmacies, and patients, the investigators concluded.
The authors have disclosed no relevant financial relationships.
American College of Cardiology Quality Summit 2021. Presented
September 29, 2021.
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