II. Definitions
- Electronic Prescription
- Transmission of a prescription electronically (typically via an EHR), directly to a pharmacy
- Meaningful use mandates as part of Stage I
III. Efficacy: Safety
- Computerized physician order entry (CPOE) has reduced some errors (e.g. illegible handwriting)
- 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
- Certain controlled substances may not be E-Prescribed as of 2019 (varies by state)
- E-prescription of controlled substances is gradually being introduced as 2 factor authentication is implemented
- Medicare Part D will require controlled substance e-prescription as of 2021
V. Adverse Effects: Common errors
- Mismatches
- Quantity is inadequate for the directions and duration
- Dosage form contradicts the directions (e.g. oral directions for a subcutaneous form)
- Automated directions contradicts the free text section
- Example: Take one twice daily for 5 days might be followed by free text of once daily
- Wrong medication
- A mouse-click slightly mis-directed
- May result in a prescription for a completely different class of medication
- Similarly named medications are grouped together in a selection list
- Examples: Metformin, Metformin XR, Metoprolol Tartrate, Metoprolol Succinate
- A mouse-click slightly mis-directed
VI. Prevention: Best Practices
- Overall approach: "Five Rights" of medication ordering
- Right patient
- Right medication
- Right dose
- Right route
- Right frequency
- Confirm the correct patient when entering orders
- Close EHR "tabs" of other patients
- Confirm correct record with demographics (patient name, age, gender, date of birth)
- Avoid multi-tasking while entering patient orders
- Confirm the correct directions
- Correct schedule of drug delivery (emergency department and inpatient)
- Drug intended for stat administration may be delayed due to scheduled dose default
- Drug intended for multiple doses (e.g. Antibiotic) may be defaulted to one dose only
- Correct schedule of drug delivery (emergency department and inpatient)
- Confirm the correct dose
- Check indications for dose adjustment (e.g. Renal Dosing)
- Check dose for children (adjusted for weight)
- Check units (e.g. mg or mcg, mg/kg)
- Proof-read Electronic Prescriptions prior to sending to pharmacy
- Electronically sent prescriptions cannot be electronically cancelled or retracted
- Prescription cancellation requires a call to the pharmacy
- Consider waiting to send medications to pharmacy until the end of the visit
- Allows for changes after full assessment
- Provide adequate medication quantity and refills
- Encourages Medication Compliance (decreased barriers to medication continuation)
- Print a medication summary at the end of a clinical encounter
- Typically an After-Visit Summary includes which medications should be stopped
- Also includes which should be changed or continued and which should be added
- Ask the patient to share the medication list with their pharmacist
- Allows pharmacist to update their records and help prevent adverse drug events
- Typically an After-Visit Summary includes which medications should be stopped
- Review most common e-Rx errors periodically with pharmacy
- Correct errors in the Electronic health record
- Example: Default prescription directions that are confusing or contradictory
- Consider Tall Man medication naming conventions
- Helps distinguish similarly appearing names (e.g. Bupropion and Buspirone)
- http://en.wikipedia.org/wiki/Tall_Man_lettering
- Correct errors in the Electronic health record
VII. Resources
- American College of Physicians - Electronic Prescribing
VIII. References
- (2014) Presc Lett 21(9): 52
- Lin and Coralic in Herbert (2015) EM:Rap 15(9): 4-6