The Case

A 48-year-old woman with a history of human immunodeficiency virus infection, migraines, polysubstance abuse, and a penicillin allergy presented to the emergency department with complaints of headache and blurry vision. Meningitis was ruled out by a negative lumbar puncture; neurosyphilis was ruled out by a negative cerebrospinal spinal fluid (CSF) fluorescent treponemal antibody absorption (FTA-ABS) test. Additional blood tests were sent out to test for other infectious causes of her symptoms, and the patient was discharged home. Following her discharge, the results of a full infectious disease panel returned showing a nonreactive rapid plasma reagin but positive FTA-ABS, a potential indication of latent syphilis. The patient was asked to return to the infectious disease clinic for follow-up.

At the follow-up appointment, the infectious disease attending recommended standard treatment: penicillin G benzathine 2.4 million units IM weekly for 3 doses. Because of her allergy history, the patient was first sent to the hospital for penicillin sensitivity testing. The plan was to initiate the penicillin desensitization protocol if she had an allergic reaction to initial testing, or to give her the first dose of penicillin and have her report to the Department of Public Health for the remaining doses if she did not.

The penicillin sensitivity test result was negative, so the allergist placed orders to initiate penicillin therapy. Recalling the patient's previous symptoms of headache and blurry vision, the allergist placed orders for neurosyphilis treatment (a far higher penicillin dose, and an inappropriate one since neurosyphilis had been ruled out). These orders included hospital admission, peripherally inserted central catheter (PICC) line placement, and penicillin G 4 million units every 4 hours via the PICC line.

On seeing the admission diagnosis of neurosyphilis, the pharmacist verifying the patient's admission orders performed a thorough chart review. The pharmacist realized that neurosyphilis had been ruled out and contacted the allergist to clarify the treatment plan. The allergist recognized the error, and the orders were corrected to reflect treatment for latent syphilis. The patient received her first IM dose of penicillin G benzathine and was referred to receive her two additional doses of penicillin. The pharmacist's catch prevented an unnecessary hospital admission, a PICC line, and multiple doses of IV penicillin.

The Commentary

by Scott D. Nelson, PharmD, MS

As shown in this case, care transitions frequently result in errors, including ones associated with medications. Communication between providers can be challenging and the deluge of details contained in electronic health records (EHRs) can make it easy to lose information. Most serious medical errors are due to miscommunication between medical providers during transitions of care.(1) The majority of medication-related problems also occur during these transitions, especially at admission and discharge.(2) The majority of admitted patients have medication errors at admission; importantly, 19% of those errors have the potential to cause patient harm (3) and 1.2%–2% are considered to be life-threatening.(4) Pharmacist involvement in transitions of care has been shown to reduce errors during transitions in and out of the hospital, decrease mortality, enhance medication list accuracy, improve allergy identification, and lower 30-day hospital readmission rates.(5) Additionally, pharmacist-led medication reconciliation has the potential to reduce medication errors by 66%.(4) Fortunately, in this case, the pharmacist's decision to review the patient's medical record, and not just the medication list, led to the prevention of a potentially costly error.

EHR use and adoption impacts how health care professionals care for their patients and communicate with each other. A 2007 survey showed that 91% of hospitals with EHRs provided pharmacists access to view parts of the EHR for medication therapy management purposes; however, only 57% allowed pharmacists to document in the EHR.(6) A follow-up 2013 survey found that 62% of hospitals required pharmacists to document their drug therapy recommendations and progress notes in the EHR as part of the patients' permanent medical record.(7) EHRs were nearly ubiquitous according to the 2015 survey, which revealed that pharmacists monitored medication therapy for more than 75% of patients in 58% of hospitals, up from 24% of surveyed hospitals in 2006.(8)

Another recent review showed that pharmacists are active users of the EHR, especially in the areas of documentation, medication reconciliation, and patient monitoring and evaluation.(9) In preparing for clinical rounds, pharmacists spend about 50% of their time reviewing and collating information from the EHR. Most of that time includes reading notes (e.g., admission notes and progress notes), followed by medication lists (inpatient and preadmission), laboratory results, and provider orders (especially over the last 24 hours).(10) Important pharmacist documentation placed in the EHR includes clinical progress notes, medication reconciliation notes, allergy documentation, comments on medication therapy (such as reasons for discontinuation or proactive recommendations), and patient education.(9) This expanded role of pharmacists has led pharmacy schools across the United States to expand their curricula to include the proper use of the EHR and how best to document assessments and recommendations.(11-13)

The increase in pharmacists' access to patient-specific health care data using the EHR and integration with clinical teams in the inpatient setting has markedly improved patient care. Unfortunately, the same cannot be said regarding ambulatory and community pharmacy settings. Community pharmacists are among the most accessible health care providers with whom patients interact. Providing community pharmacists with a medication profile (and refill history), vital signs, laboratory test results, diagnoses and current conditions, medical history, and physical assessment data has the potential to improve continuity of care and patient outcomes.(14) Other countries, such as Australia, share some EHR data with community pharmacies on a national level, affording community pharmacists access to these important data.(15) In short, pharmacists, and other clinicians, should have access to their patients' medical records, regardless of where care was received.(16)

Some pharmacist challenges are similar to those faced by other clinicians: reimbursement concerns (financial justification for services), time constraints, acceptance by other health care providers, and medical liability. Additionally, pharmacists must navigate workflow issues posed by data interoperability constraints in the retail and community pharmacy setting.(15,17) To help alleviate some of these challenges, and to monitor higher volumes of patients, pharmacists typically utilize data-mining functionalities in the EHR (such as automated reports, dashboards, or analytics), clinical surveillance software (such as TheraDoc, Sentri7, MedMined), while continuing to regularly perform manual chart review.(8) New advances in EHR data mining, health information exchange, natural language processing, patient risk scoring, and adverse drug event detection may facilitate identification of the necessary information.

As demonstrated in this case, engaging pharmacists in transitions of care is beneficial and should extend beyond simply keeping the medication list "clean." Medication therapy monitoring and evaluation is an essential and shared responsibility among health care professionals. In an era of increasing EHR use and fragmented care across different settings, pharmacists play a valuable role in optimizing safe and efficient care and helping to bridge the gaps inherent in care transitions. This case, which represents a great catch, illustrates the potential of pharmacists to prevent adverse events.(18)

Take-Home Points

• Medication errors during transitions of care, particularly at admission and discharge, are common.
• Pharmacists are active users of and contributors to the electronic health record, going beyond simple medication list review.
• Monitoring and evaluation of medication therapy is a shared responsibility among all health care professionals.
• Pharmacists play an essential role in optimizing safe and efficient medication therapy, while bridging gaps inherent in transitions of care.
• Access to electronic health record data in the community pharmacy setting is necessary and has the potential to optimize the most safe, effective medication therapy.

Scott D. Nelson, PharmD, MS Assistant Professor, Biomedical Informatics Vanderbilt University Medical Center Nashville, TN

References

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