When a computer isn't enough: Why patients need to doublecheck a doctor’s electronic prescription

The good news from our standpoint as a medication safety organization is that prescriptions that are handwritten are quickly becoming a thing of the past. According to a report last month form the nation’s leading router of electronic prescriptions, Surescripts, the number of doctors who now prescribe electronically has grown from 74,000 at the end of 2008 to 234,000 by the end of 2010. This represents 36 percent of office-based physicians. This is indeed good news. Mix-ups due to bad handwriting, look-alike drug names and other medical errors, are expected to decline along with growth in “e-prescribing.” But as with almost any kind of advance, along with the expected improvements come some unintended consequences.

One issue that’s arisen is something that’s akin to doctor’s calling prescriptions to the pharmacy without telling you what's being prescribed, which leaves you clueless about what to expect. With e-prescribing, we’ve been noticing is that consumers may be leaving the doctor’s office without anything in hand. In the past, you at least got a handwritten prescription, where you could usually make out the drug name. With e-prescribing, if you don’t get anything in writing, you may not know what to expect at the pharmacy. If the pharmacist hands you something that doesn’t seem right based on your expectations, then it might just be that an error has happened. Now you may not even have a chance.

A colleague told us about an experience he had at the doctor’s office with e-prescribing. He and his wife took their daughter to a doctor for a skin rash. The doctor prescribed a topical corticosteroid, using a handheld device to send the order electronically to the pharmacy. The doctor asked the couple which pharmacy they’d like to use, which, all in all, seemed very efficient. Except the doctor never told the family exactly WHAT drug he was prescribing or how it should be taken. He just instructed the parents to pick up the medication at their community pharmacy.

My colleague left for the pharmacy, but while in transit he and his wife began to realize that since they had no idea what the doctor prescribed, they also didn’t have anything to go by to know if they were getting the right prescription for their daughter. No error happened, but my colleague warned that this lack of information secondary to electronically prescribing directly to the pharmacy could eventually lead to some patients getting the wrong medication. They might just accept anything the pharmacist handed to them.

We heard from a woman last week whose husband had that happen. The husband visited his doctor for an infection on his hand and his doctor submitted an electronic prescription to the family’s pharmacy. At the pharmacy, the man picked up an oral antibiotic along with an ointment, which he began to apply as directed on the label. The next day he got a call from the pharmacy about a mistake that had been made. The husband’s doctor had only prescribed the antibiotic. The ointment was actually for a patient who arrived at the pharmacy right after him. A pharmacy technician accidentally forgot to change prescription records in the pharmacy computer when typing the other patient’s ointment prescription. Thus, both the antibiotic and the ointment were listed under her husband’s name and the labels as well as receipts attached to the bag had his name on them. As predicted by my colleague, the prescription had been sent directly to the pharmacy without verbal instructions by the doctor and without the patient receiving anything in writing. So the patient didn’t know what to expect.

In neither case did any harm result but these incidents still raise an important concern about prescriptions sent electronically to pharmacies: how will the patient know what they’re supposed to receive if they are not told the prescribed medication, strength, and directions for use, and given a printed copy of the information to compare with the dispensed medication? Thus, e-prescribing may contribute to an unintended weakness in the safety system.

Some e-prescribing systems print out the prescription for the patient to take to the pharmacy rather than send it directly. But other times, e-prescriptions are faxed from the office computer to the pharmacy, or sent electronically, directly to the pharmacy computer system queue, which is the ideal for e-prescribing since it reduces the need for an errant transcription. Patients should always receive verbal instructions from the prescriber, be given an opportunity to ask questions, and, with e-prescribing, also be provided with some sort of corresponding “voucher” that lists the prescribed medication, dose, and directions for use. Then the patient can use the voucher to check the prescription by matching it to what he or she actually receives in the pharmacy to assure it is the correct medication. Also, if they know what to expect, they can choose to first read about the drugs at home and formulate any questions for their pharmacists before picking up prescriptions, or contact their physicians if they have concerns about taking the medications. You should check about this with your doctor’s office during your next visit.

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