Sunday, July 12, 2009

Keeping the Rx train on track

The medication use system is hooked together, kind of like cars on a train. And the cars would be labeled:
  • prescribing

  • dispensing

  • administering

  • monitoring
Seminal medication error literature suggests that errors originating in the prescribing car account for about 40% of all errors and represent 28% of harm-causing errors. Nearly 1/2 of errors that arise during prescribing are picked up before they reach a consumer, mostly because the cars that follow contain check points and feedback loops to detect and right the error. But this means that a substantial number of errors remain undetected, errors that potentially harm patients, or in some way derail the intended plan of care.

Computerized Prescriber Order Entry (CPOE) holds the promise of increasing the reliability of activities that occur in the prescribing car. Automation ensures that patient allergies, duplication of therapy, and potential drug interactions are considered during each prescribing cycle in a way that reliance on even the most diligent human cannot.

When CPOE's best potential is realized, active errors originating in the prescribing phase will be reduced. So will passive errors that occur when high-stakes drug information is not transmitted across the continuum of care and is not readily available to treating clinicians.

Depending on the outcome of national discussions surrounding the use, the meaningful use, of 20 billion health IT-earmarked dollars, the average Walmart shopper can expect to see universal e-prescribing, ummm, soon. Until e-prescribing is fully implemented, people in the U.S. will live (or not, as the case may be) with hybrid systems.

Here's what I tell consumers to do to decrease the chance that a prescribing error will make it home:

1. When you receive a prescription for a medicine, it should be legible. Ideally, this means that the prescription is sent to your pharmacy electronically and you receive a printed copy. If it's not an electronic system, and you have to hand-carry a prescription to the pharmacy, it should be legible.

A "legible" handwritten copy of a prescription is one you can read. (It's not necessary for you to understand every word, term, or symbol, but you should be able to see and distinguish each word and number clearly). Pharmacists and pharmacy technicians have a lot of specialized knowledge, especially about drug names and products that are currently on the market. But they don't receive CIA-level training to decode poor penmanship. Making "an educated guess" is not what they're supposed to do nor is it what you want them to do. (Think of your prescription like the directions a pilot receives. Would you be willing to taxi to a runway knowing the pilot received directions he couldn't read clearly?)

2. Know what's included on your prescription and why it's important:
  • who is prescribing it

  • who it is being prescribed for

  • the date of birth of the patient (or another identifier in addition to the patient's name)

  • known drug & food allergies of the patient

  • the name of the drug

  • the dose of the drug

  • how many pills or how much liquid should be taken in order to achieve the desired dose

  • how often the drug should be taken (usually expressed in "times per day" or "times per week")

  • the quantity the prescriber is authorizing (how many pills or how much liquid you will receive)

  • the number of refills you may receive

  • the reason for taking the drug
When your prescriber (the doctor, nurse practitioner, or PA) includes the reason for the drug on the prescription, it provides another layer of information (a redundancy) to help ensure the correct drug is dispensed. 1,400 commonly prescribed drugs appear on lists of regularly confused drugs. Few of these drugs are used for the same purpose. This means that in the event your prescriber doesn't write clearly or the drug name is misread in the pharmacy, the pharmacist performing the final check has another "match point" to help detect an error. In a high-stakes, high-consequence process like medication use, you want lots of checks and double checks. (Medicine may look like candy, but it's not.)

3. Finally, when you pick up a prescription, open the bottle and look at the pills. When you're asked to sign for a prescription, you're likely signing something that says you have no questions and don't require/request additional face time with the pharmacist. Everyone has a least question when picking up a medication, and the question is this: "Did I get the right drug?" Look at the label, or ask that it be read to you. Is this the medicine you expected to get? Is the dose correct? If the name or appearance is different, the pharmacist can explain why (perhaps a generic brand was substituted) or an error that's been set in motion can be detected before you take the medicine home.

Perhaps the most worrisome thing about transitioning to e-prescribing is IT's guiding principle: "garbage in, garbage out." Take a look at this old-fashioned prescription, written just a few months ago for a member of my family.

Although the elements recommended for inclusion in any prescription are easy to list (see above), they are not included on the pre-printed prescription form used by the group of prescribers, a format used by the majority of prescribers in my community. (I blanked out most identifying info but left the "Children's" portion intact to remind myself--and you--that children are among those most at-risk-for-medication-errors and most likely to suffer harm when an error occurs.)

This process is garbage, folks. Just ask the IT person who is trying to automate it.

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