Quality and variability of patient directions in electronic prescriptions in the ambulatory care setting.
Approach to Improving Safety
Setting of Care
Electronic prescribing has yielded unequivocal improvement in outpatient medication safety. However, electronic health record prescribing infrastructure differs substantially, which creates safety hazards when prescribers transmit information to pharmacies. Researchers examined 25,000 prescriptions sent to a retail pharmacy chain and described variation in the Sig line—prescriber instructions for how a patient should use a medication. The 501 separate electronic prescribing systems generated 832 different ways to communicate the simple instruction: "Take 1 tablet by mouth daily." About 10% of prescriptions posed a potential safety hazard. An AHRQ tool provides standard language to clarify directions for patients regarding how to take their medications. A previous WebM&M commentary discussed strategies for pharmacies, clinics, and providers to mitigate the risk of patient confusion.