Thursday, November 26, 2009

Electronic Prescriptions: Now We Can Clearly Read All the Errors

I might be the only pharmacist in the world saying this, but I don't care. I'm so sick of electronic scripts. I swear I spend more time calling doctors' offices clarifying electronic scripts than I ever did for written ones.

The problem with electronic scripts is that you actually have to know how to use the program in order to send them accurately. Now, I have no idea what the software interface looks like. I just know how they show up on my computer, and often, there's some sort of problem with them.

The most common problem is whoever is inputting the script (medical assistants, RNs, and seemingly rarely the physician) keeps selecting the wrong drug. I can only assume that the interface is similar to our pharmacy computers where you type in at least part of the name of the drug and then choose the correct one from a long list of options. The problem is that while pharmacy employees work with these drugs every single day and are well aware how they're named and supplied, doctors' representatives seem to not really know which is the correct drug to choose.

Here's an example...

Drug: Tussirex
Sig: Take 1 teaspoonful q 12h prn
quant: 4 ounces

I don't even know what Tussirex is. Upon looking it up in the PDR, it apparently existed at one time as some sort of cough medicine. I've never seen it, and I'm pretty sure it doesn't exist anymore. Of course, any pharmacist knows that it was supposed to be for Tussionex. However, I can't just assume that. I've seen physicians write for products that are no longer available plenty of times before. Therefore, and especially since Tussionex is a controlled substance, I had to call the office to verify it. As you could have guessed, by the time we got the script, the office was closed and was no longer accepting phone calls. When we finally contacted the office a day later, the nurse confirmed what I already knew; She had selected the wrong drug.

Problems like that are amazingly common. Wellbutrin is another one that drives me crazy. Whenever I see an electronic script for Wellbutrin, there's probably about a 50% chance it was inputted incorrectly. There are 3 different formulations of Wellbutrin. There's just plain old Wellbutrin, the 12 hour Wellbutrin SR, and the once daily Wellbutrin XL. It's not at all uncommon to see scripts that read just like this...

Drug: Wellbutrin SR 12 Hour 150 mg
Sig: Take 1 tablet once daily.
quant: 30

This drives me insane because there are so many things that could be wrong with that script that even after calling the office, it usually takes forever for me to get it resolved. Was it supposed to be for Wellbutrin SR? If so, are they really only taking it once a day? Shouldn't it be twice daily with a quantity of 60? Or did the doctor really mean Wellbutrin XL, and someone just selected the wrong Wellbutrin? AHHHHHH!!!!

Then there's the ones that come across with completely messed up directions...

Drug: Klonopin 0.5 mg
Sig: Take 1 po qd po 1 po HS (30 days)
Quant: 60

That's exactly how the script came across. My first thought was that the doctor meant for the patient to take it twice daily. That seemed to make sense. The quantity was for 60, and it said 30 days in the directions. It looked pretty obvious to me, but once again, it was a controlled substance, so I just wanted to double check. Of course, I couldn't get anyone at the office right away, so I had to leave a message. Five hours later the doctor called back to say that it was only supposed to be 1 tablet at bedtime, and he had no idea why the script got messed up like that.

A lot of pharmacists probably would have filled that as twice daily, and it would have been an error (albeit not really the pharmacist's fault) because it wasn't what the doctor intended. That leads me to wonder just how many scripts are filled incorrectly due to someone in the office choosing the wrong drug or inputting the wrong directions? I'm guessing more than a few.

I think that electronic scripts were aimed at solving one prescribing problem: Bad handwriting. However in doing so, they opened up the potential to make plenty of other mistakes. In reality, bad handwriting was never the biggest source of prescription errors. The biggest problem causing incorrectly written (or filled) prescriptions is not double checking them before they go out the door. Prescribers (or whoever is actually writing the scripts, which I know often times is just the medical assistant, and the doctor just scribbles his signature on it) just quickly write out a script without ever giving it a second look. Therefore, careless mistakes are made. Usually the handwriting is at least good enough for pharmacists to figure out. I really don't call offices that much to clarify poor handwriting. Most of my calls for clarification involve the actual content of the prescription. Wrong drug, wrong dosage, wrong directions, wrong or missing quantity, etc. Without making double checking mandatory, these errors will continue to happen whether the scripts be hand written or electronically sent.

What I don't understand is why there's no emphasis on double checking the script before it ever leaves the office. Pharmacists double and triple check every single prescription before it leaves the pharmacy. If I'm the only person working, I will type the script myself. Then once the label prints, I will check what I typed against the hard copy. Then, I will grab the drug from the shelf and check the NDC on the bottle vs. the NDC on the label. Then I'll count it out. If it's a control, I'll double count it. Then, I'll check the name on the bottle vs. the name on the pharmacy receipt that gets stapled to the bag. Finally, I'll verify the patient's address before giving the prescription to them.

Notice that there's a half dozen checks in there for each script I fill. However, prescribers don't seem to even do a single double check. I know decreasing insurance reimbursements have them strapped for time while trying to fit as many patients in as possible. However, I can't imagine that it would take more than 5 seconds to check a prescription one just wrote for accuracy.

There's no excuse for the number of mistakes I see. Absolutely none at all, and since electronic scripts, at least from my observations, aren't doing anything to cut down on these mistakes, what's the point?


was1 said...

the old adage 'garbage in, garbage out' holds true. unless there's a blazing error, i fill it like they order it.

if the patient tells me something is wrong i offer to make a phone call but that usually results in at least a day's delay and an extra trip to the store. just in the past week i've had a patient switched from naproxen to naproxen EC in error, another switched from kcl 20meq tabs to kcl 10meq caps (2qd) in error and a third switched from doxycycline 100mg caps to tabs in error. small mistakes, but mistakes still.

i showed the patients the paperwork and asked if they were aware of any changes. then i offered to make a phone call or fill it as ordered. in all 3 of these cases the patients said to let it slide and they would call the doc themselves. i hope the message gets through.

Anonymous said...

What chaps my ass are the "Brand Medically Necessary" rxs for Flonase, Augmentin, Zithromax, etc. I used to call to clarify (generic was ok in all situations). I wasted lots of time doing this. Now, I tell pt that MD wanted brand name. They'll need to call to get it straigthened out.

Anonymous said...

My favorites are the doctors who tell the patient to just go to the pharmacy and the prescription will be ready and waiting for them when they get there. They have no idea of what the volume is at the pharmacy, how long it takes for the prescription to show up in your computer, and whether there will be a problem with the Rx they send.. I feel like telling the patient who shows up with symptoms that require a doctor's visit to just go over to the office and they will see them right away.

Anonymous said...

I hate to disagree with you but I will...

I am in a store that process about 90% of my Rxs electronic. I used to complain like you do and bitch about the little errors, mispellings, questionable sigs etc.

Then I volunteered to work at another store across the state. All hand written rxs, no doctor's info, just a local ER and a signature only, nothing printed on the Rx, no DEAs etc.

Also, if the doc hand writes the Rx and you cannot read it, and the office cannot read it, and the doc may not have a copy of it, it takes 3 hours to get to the doc to figure it out, who does that help? If you have an eRx the office has a copy of it so you don't have to describe the signature or other BS you have to do.

Having worked at the other store, I realize how good I really have it and do not complain any more!

Anonymous said...

I disagree with all of you! I'd like to say that I would never let the patient clarify a script or pharmacy-matter, even brand vs. generic. In my state, it was a three-sided agreement for brand name only--including the patient's consent.

My favorite prescriber was a self-conscious almost-retiring surgeon who always typed his prescriptions because he had heard once that pharmacists couldn't read his writing (but, I could always read his notes, and orders in the patients' charts!)

rpn0111 said...

Actual directions for Yasmin* e-rx received yesterday: "Take 84 tablets po one time per day" (Isn't Plan B easier and cheaper??)

ThePharmacyIdealist said...

E-prescribing certainly has its problems, but I believe it is better than the alternative.

Also, we forget that it is a relatively new technology and many physicians/nursing staff are still not comfortable with using computers. Once the workforce shifts more towards the newer grads from this generation I think many of these errors may lessen. Additionally, some of the responsibility lies in the hands of those setting up these EMR systems. They need to make it difficult to choose a stupid selection (like one that no longer is manufactured) through having the first list show up commonly used meds then having to make another click for a full list.

So hopefully it improves, but I think it will. It is always good to double check with the prescriber like you do though, I would never leave it up to the patient to do so.
(Also, we could even do one more final check if everyone used the show and tell method upon consultation to add a 6th check :P, so I don't think double-checking at the prescriber level is unreasonable.)


pharmacy chick said...

I dont like escripts for a dozen reasons. First they pop up on our screens in the middle of other things I am doing and will not friggin go away until somebody has dealt with it. Secondly they are fraught with errors that I am left to clear up. Third, they are time delayed. They do not instantly show up at my pharmacy when they are transmitted from the office and freqently the customer beats the script to the store.."BUT I SAW him send it!" yes you did, but its not here YET. and lastly, they do not interface well with our software. MA types in #1 for boxes of birth control, tubes of cream,inhalers, eye drops, and the like which requires intervention on our part to assure proper filling. Birth controls are in multiples of 28..not 1. and no cream I have ever dispensed has come in a 1 gm tube. AND the only inhaler I have ever dispensed that has a quantity of 1 is Asmanex.

Anonymous said...

nothing bother me most, when cannot get the doctor to correct an error because he is on vacation.

Anonymous said...

I got an e-rx today that said:

Therapoxyhine 650-100mg
generic: propxyphene/apap/dietary suppl.

How in the fuck is that even possible?

It almost seems like a legit product that would be darvocet-n-100 plus a vitamin of some sort. Nothing like that exists to my or my computer's knowledge.

The patient had been on DN100 for a few years, so that's what they got this time. Maybe Therapoxyphine is something in Canada, but on the e-rx database?