Pharmacy dispensing of electronically discontinued medications.
Approach to Improving Safety
Setting of Care
Electronic prescribing systems have been shown to prevent medication errors in the outpatient setting. However, such systems do not routinely notify pharmacies if a clinician has decided to stop prescribing a medication, creating the potential for harm. Conducted in 15 primary care practices that use a commercial electronic medical record system, this study found that 1.5% of prescriptions discontinued by physicians were subsequently dispensed at least once by pharmacies. Since these medications included high-risk therapies such as antidiabetic and antiplatelet agents, some patients may have experienced preventable harm as a result. This study identifies a previously undocumented type of error in ambulatory care and describes the need to harness technology to facilitate bidirectional communication between providers.