The February 5, 2014 Risk E-Notes article "Information About Electronic Prescribing" resulted in the following "lesson learned" from a fellow CAP physician.
It is common knowledge in the health care industry that medication errors are a large percentage of preventable harm to patients. As noted below, even the "new" world of electronic prescribing cannot prevent some medication errors.
Lesson learned: When making a medication change or having a patient stop a medication, the physician must take appropriate steps to actually stop the old medication or previous dose, whether it is through an electronic system, fax notification, or picking up the phone and contacting the pharmacist. Otherwise if the former medication/dose still has refills, it will be filled and the patient may take duplicate or discontinued meds thinking that the pharmacist knows best.
Even in this electronic world of pseudo-perfection, [it is] always best to have patients bring in all meds periodically for physical inspection. This is time consuming but can be quite revealing.
Thank you, Dr. M, for bringing this to our attention!
Authored by
CAP's Risk Management & Patient Safety Department
If you have questions about this article, please contact us. This information should not be considered legal advice applicable to a specific situation. Legal guidance for individual matters should be obtained from a retained attorney.