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Cases & Commentaries
- Web M&M
Helen Pervanas, PharmD, RPh, and David VanValkenburgh; August 2018
Admitted to different hospitals multiple times for severe hypoglycemia, an older man underwent an extensive workup that did not identify a corresponding diagnosis. During his third hospitalization in 6 weeks, once his glucose level normalized, the care team believed the patient was ready for discharge, but the consulting endocrinologist asked the family to bring in all the patients' medication bottles. The family returned with 12 different medications, none of which were labeled as an oral hypoglycemic agent. The resident used the codes on the tablets to identify them and discovered that one of the medications, labeled an antihypertensive, actually contained oral hypoglycemic pills. As the patient had no history of diabetes, this likely represented a pharmacy filling error.
Journal Article > Study
Addition of electronic prescription transmission to computerized prescriber order entry: effect on dispensing errors in community pharmacies.
Moniz TT, Seger AC, Keohane CA, Seger DL, Bates DW, Rothschild JM. Am J Health Syst Pharm. 2011;68:158-163.
Dispensing errors in the community setting are a frequent source of concern despite greater adoption of computerized prescriber order entry (CPOE) and barcode technologies. This study added e-prescribing technology to an existing CPOE system and evaluated discrepancies between prescribers' orders and the dispensed prescription information. Investigators captured more than 11,000 prescriptions written in the control clinics and nearly 30,000 in the e-prescribing ones to compare rates before and after implementation. E-prescribing was associated with a statistically significant reduction in dispensing errors, by nearly half, compared with printing a prescription out of a CPOE system and then handing it to patients. The authors advocate for this feature as a meaningful intervention to improve medication safety. A past AHRQ WebM&M commentary discussed a dispensing error that originated from a poorly handwritten prescription.