This column was prepared by the Institute for Safe Medication Practices (ISMP), an ECRI affiliate.
A health system specialty pharmacy recently reported errors related to choosing the incorrect refill dose (eg, maintenance vs loading dose) of a self-injectable medication within an integrated pharmacy software system. When the specialty pharmacy system integrated into an electronic health record (EHR) years prior, specialty pharmacists worked closely with providers and clinic staff to create order sets to accommodate medications that required both a loading and maintenance dose. The order sets effectively coupled the regimens together and drove clear prescribing practices. However, the linked prescriptions generated from the order set inadvertently contributed to errors during the pharmacy dispensing process.
With the loading and maintenance dose prescriptions being linked, deactivation of one prescription (for example, the loading dose) led to inadvertent discontinuation of the linked prescription (eg, the maintenance dose) from the patient’s profile. To prevent inadvertent discontinuation, the pharmacy chose to keep both the loading and maintenance dose prescriptions active on the patient’s pharmacy profile for the life of the prescription (up to one year). However, this has allowed pharmacy staff members to accidentally choose the incorrect dose during the refill process (eg, dispense a loading dose when the maintenance dose was indicated). In addition, it was reported that, when viewing a patient’s profile in the integrated pharmacy system, both prescriptions look identical, and pharmacy team members need to open each prescription to view the details (such as patient instructions).
Adding another layer of complexity, this specialty pharmacy utilizes a central fill system, which operates on a software system separate from the integrated pharmacy program. To mitigate the risk that the wrong prescription (eg, loading vs maintenance dose) is transmitted to the central fill operation, the specialty pharmacy added a second pre-verification pharmacist check prior to pushing the prescription from the integrated system into the central fill system. This additional pharmacist check serves as the final review of the full prescription and accompanying clinical notes to ensure the correct dose was chosen. The pharmacist adds prescription notes during this step to communicate to the central fill production team that the dose is intended to be either a “loading” or “maintenance” dose.
It is important to understand the EHR’s and/or pharmacy computer system’s definitions of “discontinuation,” “deactivation,” and “hold.” Educate all members of the interdisciplinary team, including pharmacy staff, about these definitions and their implications for workflow. Build order sets such that they will generate separate loading dose and maintenance dose prescriptions with unique start/stop dates. Prescriptions should include the indication of the medication (eg, ICD-10 code and full-text description), and the patient directions should include “loading dose” or “maintenance dose.” Work with Information Technology staff and your computer system vendors to ensure the full prescription details are accessible and visible on a patient’s profile.