II. Definitions

  1. Electronic Prescription
    1. Transmission of a prescription electronically (typically via an EHR), directly to a pharmacy
    2. Meaningful use mandates as part of Stage I

III. Efficacy: Safety

  1. Computerized physician order entry (CPOE) has reduced some errors (e.g. illegible handwriting)
  2. However, CPOE has introduced many new types of errors (e.g. selection list errors, default directions)

IV. Contraindications: Medications that may not be E-Prescribed

  1. Certain controlled substances may not be E-Prescribed as of 2019 (varies by state)
  2. E-prescription of controlled substances is gradually being introduced as 2 factor authentication is implemented
    1. Medicare Part D will require controlled substance e-prescription as of 2021

V. Adverse Effects: Common errors

  1. Mismatches
    1. Quantity is inadequate for the directions and duration
    2. Dosage form contradicts the directions (e.g. oral directions for a subcutaneous form)
    3. Automated directions contradicts the free text section
    4. Example: Take one twice daily for 5 days might be followed by free text of once daily
  2. Wrong medication
    1. A mouse-click slightly mis-directed
      1. May result in a prescription for a completely different class of medication
    2. Similarly named medications are grouped together in a selection list
      1. Examples: Metformin, Metformin XR, Metoprolol Tartrate, Metoprolol Succinate

VI. Prevention: Best Practices

  1. Overall approach: "Five Rights" of medication ordering
    1. Right patient
    2. Right medication
    3. Right dose
    4. Right route
    5. Right frequency
  2. Confirm the correct patient when entering orders
    1. Close EHR "tabs" of other patients
    2. Confirm correct record with demographics (patient name, age, gender, date of birth)
    3. Avoid multi-tasking while entering patient orders
  3. Confirm the correct directions
    1. Correct schedule of drug delivery (emergency department and inpatient)
      1. Drug intended for stat administration may be delayed due to scheduled dose default
      2. Drug intended for multiple doses (e.g. antibiotic) may be defaulted to one dose only
  4. Confirm the correct dose
    1. Check indications for dose adjustment (e.g. Renal Dosing)
    2. Check dose for children (adjusted for weight)
    3. Check units (e.g. mg or mcg, mg/kg)
  5. Proof-read Electronic Prescriptions prior to sending to pharmacy
    1. Electronically sent prescriptions cannot be electronically cancelled or retracted
    2. Prescription cancellation requires a call to the pharmacy
    3. Consider waiting to send medications to pharmacy until the end of the visit
      1. Allows for changes after full assessment
  6. Provide adequate medication quantity and refills
    1. Encourages Medication Compliance (decreased barriers to medication continuation)
  7. Print a medication summary at the end of a clinical encounter
    1. Typically an After-Visit Summary includes which medications should be stopped
      1. Also includes which should be changed or continued and which should be added
    2. Ask the patient to share the medication list with their pharmacist
      1. Allows pharmacist to update their records and help prevent adverse drug events
  8. Review most common e-Rx errors periodically with pharmacy
    1. Correct errors in the Electronic health record
      1. Example: Default prescription directions that are confusing or contradictory
    2. Consider Tall Man medication naming conventions
      1. Helps distinguish similarly appearing names (e.g. Bupropion and Buspirone)
      2. http://en.wikipedia.org/wiki/Tall_Man_lettering

VII. Resources

  1. American College of Physicians - Electronic Prescribing
    1. http://www.acponline.org/running_practice/technology/eprescribing/

VIII. References

  1. (2014) Presc Lett 21(9): 52
  2. Lin and Coralic in Herbert (2015) EM:Rap 15(9): 4-6

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