Medication errors are a significant problem in healthcare. In a recent RazorMetrics blog, we found that errors cause between 7,000 – 9,000 excess deaths in the United States every year. Complications that result from taking the wrong medication or the wrong dosage add another $40 billion to healthcare costs.

One particular error – a medication that is dispensed after it has been discontinued – poses a high risk to patients. Patients end up taking medication for an acute condition as if they were being treated for a chronic illness. Patients experience clear harm both physically and financially when they buy and take medication they no longer need. It’s estimated that 1.5% to nearly 5% of drugs are dispensed after discontinuation, with approximately 34% of these cases posing a high risk of potential harm to patients.

Electronic health records (EHR) made e-prescriptions possible, which revolutionized the healthcare industry. E-prescribing saves time for both patients and doctor’s offices. E-prescribing likely decreased misinterpretations of handwriting, but the process is not fool-proof. E-prescribing has its own challenges.

1. Omissions and errors. A doctor may forget to add necessary information or choose the wrong drug from a drop-down menu. It takes the pharmacist more time to deal with inaccuracies or missing information in e-prescriptions. 
2. Auto-Fill. E-prescribe software offers auto-filling and suggestion options. Drug names can be very similar, and the auto-fill may suggest the wrong one. It is surprisingly easy to make this mistake. The dosage is also auto-fill and the system frequently offers the most prescribed dosage. Patients who need a new or customized dosage may end up with the wrong quantity.
3. Info Mismatch. Physicians and pharmacists may use different versions of a patient name or medication. For example, the physician uses “Cindy Jones” but the pharmacist has the name as “Cynthia Jones.” The physician uses “AMH” but the pharmacist knows “amiloride hydrochloride.” These mismatches cause delays and can lead to the patient taking home the wrong medication.
4. Refill Auto-populate. During the refill process, the software often carries over the initial prescription, even when the prescription has changed. This is an easy error to miss.
5. Cancellation Timing Problem. When a prescription is entered and signed but then deleted a short time after due to an error, the prescription may still show up on the pharmacist’s system. Meaning the patient gets the wrong drug or an extra medication. In either case, it can be a costly error for the patient.

A recent study by the National Institute of Health (NIH) examined discontinuations and found that canceled e-prescriptions are still dispensed. It is critical to mitigate this issue to protect patient safety and their pocketbooks. The NIH findings suggest that by closing the loop between the prescribing physician, patient, and pharmacist, the number of e-prescription mistakes can be dramatically reduced.

RazorMetrics has developed AI to search for medications that are likely being dispensed in error or fall into a list of medications that are normally short-term treatments, but the patient has been taking it for longer than is medically recommended. We contact the physician directly to request a medication review to verify the patient still needs the medication. If not, the physician will likely choose to discontinue the prescription. Then, we contact the pharmacy to make sure the discontinuation order is processed correctly.  

RazorMetrics’ discontinuation solution offers a promising way to benefit patients and their health plan or employer in the ongoing pursuit of safer and more efficient pharmacy practices. The savings from catching medication errors are considerable.