Strategies for Reducing Medication Errors in Era of E-Prescribing

Taking the wrong medication or the wrong dose of a medication can result in great physical harm to patients. Medication errors are especially concerning among those seeking psychiatric care, as the high frequency of co-occurring general medical and psychiatric illnesses amplifies the potential dangers of medication errors.

In the case of the outpatient psychiatric setting, where a solid therapeutic alliance is an essential aspect of the patient-physician relationship, even errors that do not lead to physical harm can have a lasting, negative impact on subsequent care (1). Patients may perceive errors as signs of physician negligence and be less likely to trust their physician in subsequent treatment decisions.

It is imperative that outpatient psychiatric prescribers make an ongoing, concerted effort to reduce the risk of medication errors. Electronic prescribing (e-prescribing) offers a pathway to achieve this goal, as errors from illegible handwriting, lost paper scripts, and incomplete or inaccurate instructions are reduced.

E-prescribing is not without its own problems. With e-prescribing, physicians may still omit crucial aspects of an order (such as dose or strength), prescribe the wrong medication, continue medications they no longer intend the patient to take, and prescribe the same medication multiple times with different instructions (2). Reasons for such oversight range from the growing complexity of medication regimens to fatigue from an abundance of on-screen automated alerts. Prescriber reliance on e-prescribing also reduces opportunities to interact with pharmacy staff, a crucial step in conveying complex instructions.

Below are several initiatives that could reduce the risk of outpatient medication errors in psychiatric settings in the era of e-prescribing, followed by suggestions for achieving these goals:

• Make e-prescribing systems more affordable for outpatient psychiatric and train providers on e-prescribing implementation.

The current structure of outpatient psychiatric practice poses unique challenges to widespread implementation. Most outpatient psychiatry is delivered in non–clinic-affiliated, private practice settings, where an e-prescribing system may be perceived as too expensive, cumbersome, and complex to warrant its use.

Up-front costs of e-prescribing implementation prevent many practices, especially small groups and solo practitioners, from using these systems. State and federal mandates to use e-prescribing systems should be accompanied by financial incentives or assistance to overcome this barrier to entry. Offering educational opportunities for providers around technological literacy and e-prescribing implementation can also bolster the success of such programs.

• Address design flaws in e-prescribing systems.

E-prescribing interfaces are often cluttered, text heavy, and redundant. Many systems also make entering information overly complex.

Replacing prompts with clear graphical user interfaces, integrating required drop-down menus (for route of administration and units of strength), and autocompleting a medication’s administered amount (calculated by the frequency and number of days prescribed) are just a few ways to make these systems more user friendly.

• Improve interoperability among proprietary e-prescribing systems.

Patients often seek care from multiple clinicians who may use e-prescribing systems that fail to communicate with each other. This fragmented system of care increases the risk of medication duplication and co-administration of various medications. 

One possible solution to this challenge is to augment health information exchanges to include a “patient-adjudicated” medication list (3). This list can be managed through a centralized, digital database that prescribers, hospitals, pharmacies, and the patients themselves could view and modify on an ongoing basis.

Although these improved lines of communication may reduce medication errors (duplicate medications, harmful drug-drug interactions), some patients may perceive an all-inclusive e-prescription system as an invasion of privacy for exposing their psychiatric care to their nonpsychiatric medical providers. One potential solution to such concerns might be to add a layer of security in the record for obtaining information about a patient’s use of psychotropic medications (akin to “break-the-glass” digital firewalls embedded in many electronic health records).

• Improve interoperability of e-prescribing systems and retail pharmacy electronic systems.

Although prescribers can confirm that an e-script has been transmitted to and even received by an external pharmacy, they currently cannot view the patient’s list of medications or the number of refills remaining. Possible solutions to these challenges include enabling prescribers to view the most current list of medications for a patient in their retail pharmacy’s system (and vice versa), allowing for real-time chat between prescribers and pharmacists (reducing the need for time-consuming phone calls), and allowing for e-discontinuation (thus ensuring that medications are stopped).

This inter-database communication could also be expanded to include state-run prescription drug monitoring programs (PDMPs). However, reliance on a PDMP would require cross-referencing an external database, leaving room for yet another source of communication error and increasing pharmacist and prescriber burden.

Patients, payers, prescribers, and pharmacists all have a role to play in advocating for these and other changes. By gradually replacing paper- and phone-based medication prescriptions with more robust, better designed e-prescribing systems for psychiatry, we can begin to address medication safety issues, medication adverse events, pharmacy-prescriber communication problems, and administrative burdens. ■