November 28, 2012
Why Pharmacists Unknowingly Fill Discontinued Medications

Boston—Pharmacists unknowingly continue to dispense discontinued medications because of a lack of communication from physicians.

That’s according to a study published this month in the Annals of Internal Medicine. It noted that more than 85,000 medications are discontinued each year by physicians, but that the information is often not shared with pharmacists, even if patients are informed.

Researchers from Brigham and Women's Hospital (BWH) and Harvard Vanguard Medical Associates called the issue an “important ambulatory patient safety concern.”

"This is a novel patient safety issue that has not been measured previously," said senior author Thomas Sequist, MD, MPH, a physician at BWH and Harvard Vanguard. "We found that 1.5% of all off discontinued medications were refilled by the pharmacy and that 12% of those refilled medications caused some degree of potential harm to the patients."

Some of the harm represented serious issues such as low blood pressure and possible allergic reactions, but other problems were less serious, such as lightheadedness or nausea.

To conduct the study at Harvard Vanguard, researchers used electronic medical records to analyze 1,218 medications that were discontinued in 2009. That information was compared to a review of a sample of more than 400 medical charts for any adverse events linked to continued use of the discontinued medication.

The authors suggest that many physicians may incorrectly assume that patients will always remember to stop taking a discontinued medication or that discontinuing a medication in the electronic health record automatically transmits that information to the pharmacy, similar to the way a new prescription is transmitted.

"The implementation of electronic health records have offered a clear opportunity to track when a clinician discontinues a medication, but now there needs to be a process that helps discontinued orders be transmitted electronically to the retail pharmacy," said lead author Adrienne Allen, MD, MPH, associate medical director of Quality, Safety, and Risk at North Shore Physicians Group. "Future research should focus on evaluating methods of improving communication between providers and pharmacies to better reconcile medication lists, as well as explore strategies to improve patient knowledge and awareness of their medication regimen.”

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