Alerting Community Pharmacy to Canceled Drugs Could Help Avoid Safety Events


Many prescriptions are sent to the pharmacy via electronic health record systems; however, the correct delivery of interrupted drugs continues to be a problem, increasing the risk of drug safety events. In a summary presented at the American College of Cardiology Quality Summit Virtual, which took place from September 29 to October 1, 2021, Intermountain Healthcare looked at several methods to alert community pharmacy staff to canceled medications, potentially avoiding nearly 200 drug events. security over two months.

Currently, there is no ideal way to notify a pharmacy that a clinician has stopped treatment for a patient, often resulting in a drug being discontinued or a dose renewed. incorrect and confuses the patient. Patients are at risk of taking a drug that is no longer indicated or at the wrong dose, which has important indications for drug safety. “

Jeffrey A. Goss, FNP-c, MSN, APP Director of Heart Failure for Intermountain Healthcare in Murray, Utah, and one of the study authors

The study was designed to determine why pharmacy communication about canceled medications was not occurring and to identify how best to communicate these changes from meeting the patient at the pharmacy. According to the researchers, Intermountain Healthcare has had a number of safety events involving stopping taking drugs with new drugs, resulting in hospitalization.

Initially, the Intermountain Healthcare team tried temporary solutions, including clinical staff (registered nurses or pharmacists) personally calling the pharmacy to alert them of medication changes and request that the medication be removed from the patient’s profile. Clinicians were also asked to document medication changes in the “comments” box of a prescription sent electronically to alert pharmacy staff of medication changes. This includes documenting information such as “this prescription replaces…”, but not all pharmacies see this information and it was not a reliable method of communication.

During the 60 days, 16 advanced practice providers from the Heart Failure / Advanced Transplant team at Intermountain Medical Center activated the CancelRX feature in their electronic medical record system. CancelRX is a function that informs the pharmacy when a drug is discontinued as if it were a new prescription. The feature was initially disabled due to a high number of error messages associated with clinicians. It also depends on whether the pharmacy has also activated this feature to receive the messages.

During the CancelRX trial, the advanced heart failure / transplant team at Intermountain Medical Center followed a total of 558 discontinued drugs. The team received 359 error messages and made 148 phone calls to pharmacies. A total of 196 potential security events were prevented using phone calls and CancelRX during the 60-day trial. The five pharmacies or chains where error messages were received by the trial team included Intermountain Pharmacies (210), Smiths (117), Walgreens (38), Costco (25), and CVS (23).

“Effective communication between the clinician and the pharmacy is essential to ensure that patients only receiveD drugs they need. In addition to the safety implications, it will also reduce the likelihood that a patient will purchase an interrupted prescription, resulting in savings for patients and insurance payers, ”said Steven Metz, PharmD, BCPS, Advanced Clinical Ambulatory Care Pharmacist, Intermountain Healthcare in Murray, Utah, and one of the study authors.

According to the researchers, better results are inherent if the appropriate medications are dispensed to patients based on the recommendations of clinicians. They recommend that healthcare systems review the way their electronic medical records system interfaces with their local pharmacies to ensure one less area of ​​potential error in patient care.


American College of Cardiology


Comments are closed.