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Pharmacies Dispense Meds Even after Docs Stop Prescription

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When doctors take patients off of a prescription medicine, it is often for a good reason. But pharmacists don’t always get the memo. A new study finds that more than 1 in 100 discontinued prescriptions were filled by the pharmacy anyway, putting some patients at serious risk.

In the U.S., pharmacists filled more than 3.7 billion prescriptions in 2011. With so many prescriptions and refills—and our still largely human- and paper-based prescribing system—there are bound to be mistakes. Pharmacists may overlook drug interactions, dispense inappropriate medications, or commit other little-understood errors.

One such underappreciated problem area is the process of taking patients off medication. While errors in initial prescribing have drawn much attention, potential for error when doctors order a prescription to stop also looms large. And electronic health records, which have helped to minimize medical errors in other areas, might be partly to blame.

These electronic communiqués might be giving some doctors—and patients—a false sense of efficacy. Doctors might assume that when they make a note on a patient’s electronic health record to stop a prescription the pharmacy will automatically get the message as it does when they first prescribed that medication. This, however, is not always the case, wrote Adrienne Allen, of the North Shore Physician Group, and Thomas Sequist, of Brigham and Women’s Hospital in the new paper, published online November 19 in Annals of Internal Medicine.

To find out how often the pharmacies continue to dispense meds the doctor no longer ordered, Allen and Sequist analyzed electronic health records of 30,406 adults in a Massachusetts health system whose doctor had discontinued a drug to treat a high-risk condition such as high cholesterol, hypertension, diabetes, blood coagulation or platelet aggregation. Some 83,900 medications were discontinued during the course of a year. Nevertheless, pharmacists still dispensed 1,218 of these prescriptions after they were discontinued. The most common drug that pharmacists dispensed after a doctor canceled the prescription was metoprolol (Lopressor or Toprol), which is often prescribed to treat high blood pressure after a heart attack and which can have harmful drug interactions with other commonly prescribed drugs.

In a subset of medical records, a computer analysis flagged more than a third (34 percent) of the improper dispensations as creating a “high risk of potential adverse events” such as a harmful reaction, potential drug interaction or suspect lab test result, the researchers noted. And manual assessment verified that potential harm actually occurred in at least 12 percent of cases.

Patients receiving these drugs were more likely to be taking more medications, older, enrolled in Medicare and black. Additional medications make it more likely that a patient will suffer an adverse drug interaction if they take an unintended prescription (especially if a doctor has subsequently prescribed a similar drug to take the discontinued drug’s place). And older adults might be less likely to notice a mistake.

One limitation of the study is that the researchers could only study the 52 percent of discontinued prescriptions that were filled at participating health care system pharmacies; unaffiliated pharmacies might have even higher inappropriate dispensation rates. Additionally, the researchers only studied a limited number of drugs. Adding other drugs to the analysis would likely increase the number of discontinued prescriptions dispensed, even if the risk of side effects might be lower.

They researchers see promise for filling this communication gap in the future. Electronic health records offer an opportunity to track these missteps, and adding more direct communication with pharmacies about prescription discontinuation should help avoid these errors.

For now, however, the new technology is often not as powerful as many doctors think it is. So some of the responsibility will continue to lie with the patient. Officials would be wise to help “increase patient awareness of their medication list,” the researchers concluded. That is, until the computers can just do it for us.

Katherine Harmon Courage About the Author: Katherine Harmon Courage is a freelance writer and contributing editor for Scientific American. Her book Octopus! The Most Mysterious Creature In the Sea is out now from Penguin/Current. Follow on Twitter @KHCourage.

The views expressed are those of the author and are not necessarily those of Scientific American.

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  1. 1. k banco 7:15 pm 11/19/2012

    I think you not have emphasized the most important aspect in all of this.

    “So some of the responsibility will continue to lie with the patient.”

    This is critical. Most ambulating patients who come in to a pharmacy to refill a prescription are well enough and able enough to figure out their drug schedule (or at least they should be). If it is for a critically ill patient where family members come in, then these patient agents are very well informed most of the time. Many of the cases then where discontinued prescriptions are continued to be released stem from patients simply being unaware or uncaring about what is going on. Why would they pay for something they aren’t to be on? The doctors also didn’t inform them well (or they didn’t listen). A pharmacist cannot check each patients EHR for each refill dispension. We DEPEND on patients being aware of what they are taking. Also, when I dispense meds, I literally show the patients their drugs and ask them if they got what they were looking for. Stopping a CRITICAL drug is something important, you’d think? Patients should be aware of this. And like I said, the ones well enough to come in and get refills themselves have the duty to know what drugs they should be on.

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  2. 2. madre7 10:47 pm 11/19/2012

    The CDC bulletin #42, reported that 64% of people >60 are taking 3 or more prescription drugs. It’s not uncommon to find elderly people taking 10+ for chronic diseases such as diabetes, heart disease and arthritis. These medications all come with time parameters, food parameters, nutraceutical parameters,and drug-drug interaction parameters to form a complex and sometimes perplexing therapy throughout the day (and sometimes night). It is not that difficult to imagine that changes in the schedule might be difficult to adjust to. Just because a patient is ambulatory doesn’t mean that they can’t make mistakes. Most assuredly, the patient should be proactive in their own health care. But just as they should be, the prescriber should be to. If the prescriber is aware (and why wouldn’t they be?) that the patient’s pharmacotherapy is complex, then the prescriber should make sure that the change in therapy is understood and sent home with the patient in writing. This will not mitigate the entire problem but it could make a dent in it.
    As far as caregivers picking up meds, did it ever occur to anyone that their load is heavy and sometimes they make mistakes? How many medication mistakes happen in a hospital where medication is only handled by medical professionals? Really, this problem is resolved not by pointing fingers but by analyzing the situation so that a real solution can be found, not by pointing fingers.

    BTW 3.7 billion…not trillion.

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  3. 3. Mykeljon1 11:40 pm 11/19/2012

    There is a simple solution. In Canada, a doctor writes a prescription for a fixed time period, usually no more than 6 months. The prescription cannot be renewed without another visit to the same doctor. The prescription that the pharmacy receives specifies the time limit. Therefore, a patient cannot continue to take a medication for longer than the doctor specifies.

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  4. 4. k banco 7:56 am 11/20/2012

    Mykeljon1: I’m a pharmacist in Canada. While it helps, in Alberta though for example, its 18 months. The problem though is that often a change is made within that time frame. Alot can change in 18 months. When it comes down to it a person needs to be responsible for themselves. Also, doctors can easily renew prescriptions. Second, they can save prescriptions and use them later on, further complicating matters.

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  5. 5. Wayne Williamson 4:53 pm 11/20/2012

    I often times have problems actually getting a drug that I have a prescription for. This probably happens 1 out of 10 times and seems to be happening more often lately.
    Which one is a more pressing problem….getting something you’ve been on or not getting something that you are on…

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  6. 6. thixotropic 3:16 pm 11/21/2012

    Electronic prescribing problems are rife in America. I now insist everything be written, as about a quarter of the time the prescription never shows up, or shows up days later.

    Another problem that’s common here: using the pharmacies’ automated refill lines, and finding the prescription was never filled. I now speak to them live every time. This is primarily a problem at the major chains, but that’s about all there is left in America.

    Off-topic but relevant: Another major problem with the chain takeover of America’s pharmacies: the quality of their generics has decreased dramatically. I must go to three different stores now to get decent generics. Generics are not created equal, and often are not as assimilable as the brand name, regardless of claims about similar blood levels. It doesn’t matter how much is in the bloodstream, if it isn’t properly usable by the body.

    The shameful thing: America talks about the dangers of foreign drugs, but I’ve gotten much better quality from India than I have with many American generics. Indian 10 mg generics that are more efficacious (and far cheaper) than American generics at twice the dose? Disgraceful. Must do better.

    There is simply too much moral hazard in allowing profit motives to drive health care decisions. It’s killing people and robbing them of effective treatments.

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