Duplicate Therapies in Retail Pharmacy
Case 1: A middle-aged man with a past medical history of heart failure with reduced ejection fraction (HFrEF) and end-stage renal disease (ESRD), on three-times weekly hemodialysis, was seen in an outpatient cardiology clinic. The cardiologist planned to switch the patient from an angiotensin converting enzyme inhibitor (ACEi) to an angiotensin receptor blocker/neprilysin inhibitor (ARNI, specifically sacubitril and valsartan) due to worsening symptoms despite standard multi-drug therapy for HFrEF.
However, when the patient returned to his primary care clinic for medication review and renewal, the pharmacy student doing medication reconciliation recognized that he was being dispensed both an ACEi and an ARNI. Although the ACEi order was discontinued in the electronic health record system, it was still active at the retail pharmacy. The patient was not harmed by concomitant ACEi and ARNI use, given that he was already on hemodialysis, but otherwise there would have been an increased risk of worsened renal function.
Case 2: An elderly patient with hypertension, morbid obesity, dementia, and heart failure was discharged home after a brief hospital stay and was told to pick up prescriptions at his local pharmacy. The retail pharmacist recognized that two physicians, a general internist and a cardiologist, had prescribed the same antihypertensive medication with different dosages. The pharmacist called both physicians’ offices for clarification and received no response. The patient and his daughter were also unable to clarify which dosage was correct. As a result of this confusion, the patient ran out of his medication and his daughter and home health nurse noted poor blood pressure control. After eight days, the pharmacist provided the patient with both medication dosages and instructed the patient to follow up with his physicians about which dosage he should take.
The duplicate therapy errors that occurred in both cases reflect fragmented care with lapses in coordination and communication as well as failure to appropriately address a medication discrepancy. In Case 1, although the ACEi was discontinued in the electronic health record (EHR), it was still active at the retail pharmacy, which did not utilize the same EHR system. In Case 2, the pharmacist identified the duplicate therapy but waited eight days before dispensing the medications. There are multiple unknown factors that may have contributed to the delay in dispensing, such as understaffing, lack of handoff, or incorrect contact information. The pharmacist may not have been comfortable making a clinical decision without having access to the patient’s medical records. This lapse resulted in poor blood pressure control, but fortunately no harmful outcomes.
Duplicate therapy errors have the potential to be serious and may result in adverse drug events (ADE), which are patient injuries related to using a drug.1 ADEs caused by medication errors can be mitigated through best practices in medication reconciliation, which is defined as the process of identifying the most accurate list of all medications a patient is taking and then using this list to provide correct medications for patients anywhere within the health care system.2 Medication discrepancies are unexplained differences among documented regimens across different sites of care,3 and medication reconciliation can reduce actual and potential harm caused by these discrepancies.2
Medication discrepancies are common and multifactorial, documented in as many as 25% to 90% of outpatient medication regimens,3 and up to 70% of patients at hospital admission or discharge, with almost one-third of those discrepancies having the potential to cause patient harm.1 Discrepancies may signal intentional or unintentional medication nonadherence, patient-provider miscommunication, low health literacy, or issues with medication costs, among other etiologies.3 The specific types of discrepancies include variation in dosage or frequency of use, not taking recorded medications (errors of omission), and taking nonrecorded medications (errors of commission). Patient counseling strategies are an important part of limiting discrepancies and may empower the patient to help correct errors. In addition to opportunities for an improved patient counseling process, both cases reflect errors that occur from fragmented care – lack of a shared platform between the prescribing physician and other healthcare providers, which limits coordination and communication. Our commentary focuses on strategies that can be utilized by the individual provider to limit discrepancies, as well as more complex systems-level approaches that address fragmented care, but may take significantly more investment and organizational buy-in.
Interventions at the Individual Provider Level
Utilize the teach-back method
Effective provider-patient communication is a cornerstone of patient-centered care and medication counseling. To make good medication-related decisions, patients and caregivers need to understand how to take their medications, how to monitor their chronic conditions, how to recognize signs of a worsening issue, and when to seek additional help.4 Merely providing verbal or written instructions may not be sufficient for education. Evidence has demonstrated that 40-80% of the information patients are told during office visits is forgotten quickly,4 possibly due to low health literacy, an overwhelming volume of information, or other distracting factors such as social stressors. Also, nearly half of the information retained is incorrect when assessed.4 One way to ensure patients understand the information provided is to use the teach-back method. This approach requests the patient explain in their own words what they need to do or know. Teach-back can help patients to remember and understand information, raise satisfaction, and build trust. When performing teach-back, it is important to speak slowly, make eye contact, use relaxed body language, avoid complex medical jargon, and use open-ended questions.5 For example, "We covered a lot today about your medications and I want to make sure that I explained everything clearly. Let's review what we discussed. What changes you will make to your blood pressure medications?” Utilizing the teach-back method during counseling is one of the most effective ways of ensuring that patients have understood all instructions provided and can, therefore, take their medications safely. The Agency for Healthcare Research and Quality (AHRQ) provides resources and training materials for healthcare providers to implement teach-back into their daily practice. It is also important to include family members or caregivers in the teach-back and discharge counseling process.
Other ways of ensuring adequate communication and counseling include:6
- Simplifying the language used in written materials to a sixth-grade reading level;
- Following up with patients a day or two after hospital discharge to make sure they understand their discharge instructions and at-home care;
- Providing interpreters and translated materials for people with limited English proficiency and patients with hearing/vision disabilities in their preferred format;
- Redesigning prescription labels to make dosage instructions simpler and easier to see and read; and
- Ensuring that the after-visit-summary for the encounter is accurate, clear, and utilizes terminology that the patient can understand.
Patient counseling, including teach-back, written directions for the patient, and smartphone medication reconciliation applications are all tools to empower patients so that when they report to the pharmacy to pick up their medications, they can also clarify their most current medications and medication changes. Furthermore, including the medication changes in the “note to pharmacy” or after-visit summary can help clarify the dose or medication change and thereby allow the pharmacist to counsel the patient. Adequate patient/caregiver counseling in both cases may have prevented these medication discrepancies.
In addition to patient/caregiver counseling, the available evidence supports medication reconciliation interventions that use pharmacy staff during transitions of care. Transitions of care (TOC) are a high-risk period for medication-related harm.3 Systematic reviews of pharmacist-led TOC interventions have documented the heterogeneity of these interventions, the lack of evidence about which TOC model is best, and improved results with multifaceted interventions or interventions of higher intensity.3 Close collaboration between pharmacists and physicians and integration of pharmacists in multifaceted programs across health settings are known enablers of successful TOC.3 For example, comprehensive and face-to-face post-discharge medicine management consultation by pharmacists who are integrated into general practices, followed by consultation with patient’s family physician, reduced a composite of emergency department (ED) visits and readmissions with substantial cost-savings for the healthcare system.7 Additionally, older age and a higher number of recorded medications are strongly associated with medication discrepancies8 and such patients may benefit from focused medication reconciliation efforts by a pharmacist. Outpatient clinical pharmacists who are embedded in the primary care clinic often perform medication reconciliation, follow up with the patient, make medication adjustments under collaborative practice agreements, assess tolerability, and provide education. They can also help to resolve any medication access or financial barriers.
In Case 1, using teach-back to assess and improve the patient’s understanding of his medications could have prevented concomitant use of the ACEi and ARNI. Additionally, directions can be specified on the medication bottle. For example, the prescribing physician could have included instructions on the “sig” to stop lisinopril and initiate the ARNI on a specified date. In Case 2, adequate discharge counseling, using the teach-back method with the patient and his daughter, could have empowered the patient to clarify the dosage of his antihypertensive medication with his physicians or retail pharmacist.
Close follow-up with a pharmacist occurred in both cases and led to identification and correction of the discrepancy in Case 1. However, in Case 2, the pharmacist failed to resolve the discrepancy and dispense the correct medication in a timely manner. At discharge from the hospital, all discharge medications are normally written by a single provider. Hard stops are built into most electronic health record (EHR) systems that prevent duplication of medications, or flags in the record to indicate that discharge medications have already been sent. However, if either physician had written an earlier or paper-based prescription, or if the physicians utilized different EHRs that did not communicate, then the pharmacy would have received duplicate prescriptions. Communications with the pharmacy and between providers may not happen consistently due to time constraints, human factors, and variability in practice.
In the hospital environment, medication management is a complex process usually involving at least four stages (1) prescribing, (2) transcription and verification, (3) dispensing, and (4) administration. Medication management is associated with a risk of errors and inefficiencies across all stages of the process.8 There is considerable variability in the estimates of medication errors reported in the prescription (approximately 10% - 39%), dispensing (approximately 11% - 40%), and administration (approximately 11 - 38%) stages of medication management with multifactorial causes.8 The pharmacist in this case should probably have released the more recent prescription and asked the patient to follow up with their physician by telephone, rather than wait eight days. Failure to appropriately address the discrepancy and dispense the medication in a timely manner reflects human error and can be due to variability in practice, lack of time or staffing, and/or barriers to communication with provider offices. It may be beneficial to ensure that policies or protocols are in place so that pharmacists are aware of what to do in certain situations where dispensing errors may occur. For example, the retail pharmacy could adopt a policy to ensure discrepancies are resolved within a reasonable time frame. In addition, retail pharmacies may also benefit from improving effective hand-off procedures to ensure cases are not lost to follow-up, especially between shift changes.
Systems level Interventions
Pharmacy-led medication reconciliation
There are several changes that organizations can incorporate to optimize systems that assist providers and address fragmented care. Best practices in medication reconciliation should become standard with every patient encounter. Medication reconciliation is resource-intensive and time-consuming, and ideally would take place under the direction of a pharmacist. Although it is not yet clear which interventions benefit the most, numerous reviews concluded that pharmacy-supported interventions are effective when nurses and physicians are in close collaboration with pharmacists and when medication interventions are bundled with other patient-tailored interventions.9 Additionally, focusing pharmacy-supported interventions on high-risk patients could improve clinical outcomes.9 Medication reconciliation can be beneficial at each transition in level of care, especially if the patient’s providers practice at different institutions or use different EHR systems. One challenge is to standardize the medication reconciliation process across different hospital systems and EHRs as there is no single gold standard and the quality of medication reconciliation can be highly variable.
Improving transmission from the EHR to the local pharmacy to catch the changed orders could have prevented the error described in Case 1 from reaching the patient. Likewise, the transmission of the patient’s discharge medication profile to the retail pharmacy in Case 2 would also have clarified the correct dosage. Unfortunately, this is not often the standard of practice and most pharmacies do not have access to patients’ medication records to review progress notes or test results.
Electronic Health Record (EHR) enhancements
Though commercial integration software systems can be costly, some programs can be used to consolidate the records of prescriptions from multiple outpatient pharmacies into the hospitals’ medication list profile. This type of software can also help identify non-adherence and potential diversion. These tools can improve time, efficiency, and accuracy of completing a medication reconciliation. Additionally, hard stops and other EHR enhancements can be built in to avoid discrepancies and errors. For example, in some software, a cancellation message is automatically sent to the patient's local pharmacy after a physician discontinues an order. However, there are still opportunities for improvement as this functionality does not consistently transmit to retail pharmacies that are not integrated into the electronic health system utilized by the hospital.
Integration of community pharmacists using web-based application
Sharing an EHR platform or interoperability between systems can enhance access to care for patients, improve cost-effectiveness and encourage sustainability in the system. In attempts to improve medication management, adherence, and chronic disease prevention, alternative payment models in the US are beginning to integrate community pharmacists into team-based care arrangements.10 Community pharmacists, with their training and accessibility, can support chronic disease prevention and management programs, assisting in adherence to medications or counseling patients on harmful drug effects. Additionally, they can assist other providers and specialists, for example, by making recommendations on dosing for renal failure, or looking for drug interactions. To perform these services most effectively, community pharmacists need access to patients’ clinical data, such as notification when a patient is admitted to or discharged from the hospital, a complete list of medications at home and upon care transitions that is updated and as close to real-time as possible, and laboratory values.10 However, implementing access to each EHR system can be challenging because community pharmacists work with many different providers.10 In addition, community pharmacies that implement new electronic documentation systems encounter barriers such as lack of time for documentation, limited training and low self-efficacy, and staff resistance to change.10 Additionally, pharmacies have reported difficulty with usability, lack of standardization across documentation systems, and lack of interoperability between the pharmacy’s management system and other documentation systems.9 To address these barriers, technology vendors are developing Web-based medication management applications that allow for the documentation of clinical services, integration of clinical data, and tracking of patient outcomes.10
Ongoing improvements in interoperability between different EHR platforms, integration of community pharmacists, and proliferation of web-based medication management applications will hopefully help to limit the frequency of duplicate therapies and other medication discrepancies as these technologies and workflow adaptations become more prevalent. In the meantime, putting together pharmacy teams that work closely with physicians and nurses, focus on high-risk patients such as those who are elderly and on multiple medications, especially at transitions of care, and employing proven patient counseling techniques, such as teach-back are likely the most effective way to limit medication discrepancies and address them in an appropriate and timely manner. Policies and procedures to address discrepancies can be implemented to ensure discrepancies are resolved appropriately.
Take Home Points
- Older patient age and a higher number of recorded medications are strongly associated with medication discrepancies.
- The teach-back method should be utilized to counsel patients and their caregivers on their medications and empower them to avoid medication errors.
- Transitions of care between different healthcare settings should be targeted for interventions to limit medication discrepancies. Pharmacy-led teams that collaborate closely with physicians and nurses should be utilized at these transitions.
- EHR programs can consolidate the records of prescriptions from multiple outpatient pharmacies into the hospitals’ medication list profile and can improve time, efficiency, and accuracy of completing a medication reconciliation.
Nisha Punatar, MD
Division of Hospital Medicine
Department of Internal Medicine
UC Davis Health
Samson Lee, PharmD, BCACP
Population Health Pharmacist
Department of Pharmacy
UC Davis Health
Mithu Molla, MD, MBA
Health Sciences Clinical Professor
Chief, Division of Hospital Medicine
Department of Internal Medicine
UC Davis Health
- Cossette B, Ricard G, Poirier R, et al. Pharmacist-led transitions of care between hospitals, primary care clinics, and community pharmacies.J Am Geriatr Soc. 2022;70(3):766-776.[Available at]
- Medication reconciliation review. Institute for Healthcare Improvement (IHI). Accessed February 28, 2023. [Available at]
- Patel CH, Zimmerman KM, Fonda JR, et al. Medication complexity, medication number, and their relationships to medication discrepancies.Ann Pharmacother. 2016;50(7):534-540. [Available at]
- Kessels RP. Patients' memory for medical information. J R Soc Med. 2003 May;96(5):219-22. [Free full text]
- The SHARE Approach—Using the teach-Back Technique: A Reference Guide for Health Care Providers. Agency for Healthcare Research and Quality (AHRQ). Accessed February 28, 2023. [Available at]
- Freeman CR, Scott IA, Hemming K, et al. Reducing Medical Admissions and Presentations Into Hospital through Optimising Medicines (REMAIN HOME): a stepped wedge, cluster randomised controlled trial.Med J Aust. 2021;214(5):212-217. [Free full text]
- Cebron Lipovec N, Zerovnik S, Kos M. Pharmacy-supported interventions at transitions of care: an umbrella review.Int J Clin Pharm. 2019;41(4):831-852. [Available at]
- Batson S, Herranz A, Rohrbach N, et al. Automation of in-hospital pharmacy dispensing: a systematic review.Eur J Hosp Pharm. 2021;28(2):58-64. [Free full text]
- Turner K, Renfro C, Ferreri S, et al. Supporting community pharmacies with implementation of a web-based medication management application.Appl Clin Inform. 2018;9(2):391-402. [Free full text]