TUESDAY, Nov. 20 (HealthDay News) — Doctors sometimes fail to inform a pharmacist that a patient has been taken off a medication, and the pharmacist continues to refill the patient’s prescription for the drug, a new study finds.
This is a newly identified and important patient safety issue, according to senior author Dr. Thomas Sequist, a physician at Brigham and Women’s Hospital and Harvard Vanguard Medical Associates, in Boston.
He and his colleagues looked at 1,218 instances in 2009 where patients’ medications were discontinued by Harvard Vanguard doctors.
“We found that 1.5 percent of all discontinued medications were refilled by the pharmacy and that 12 percent of those refilled medications caused some degree of potential harm to the patients,” Sequist said in a Brigham and Women’s news release.
Harm ranged from serious problems, such as low blood pressure and possible allergic reactions, to less serious issues, such as nausea or lightheadedness, according to the study, published in the Nov. 20 issue of the journal Annals of Internal Medicine.
Many doctors may incorrectly assume that a patient will remember to stop taking a drug after they have been taken off it, or that discontinuing a medication in a patient’s electronic health record is automatically transmitted to the pharmacy, in the same way that a new prescription is transmitted, the researchers said.
“The implementation of electronic health records have offered a clear opportunity to track when a clinician discontinues a medication, but now there needs to be a process that helps discontinued orders be transmitted electronically to the retail pharmacy,” study lead author Dr. Adrienne Allen, associate medical director of quality, safety and risk at the Boston-area North Shore Physicians Group, said in the news release.
“Future research should focus on evaluating methods of improving communication between providers and pharmacies to better reconcile medication lists, as well as explore strategies to improve patient knowledge and awareness of their medication regimen,” Allen added.
More information
The Institute for Safe Medication Practices offers advice for safe medication use.