TUESDAY, Nov. 20 (HealthDay News) -- Doctors sometimes fail to
inform a pharmacist that a patient has been taken off a medication,
and the pharmacist continues to refill the patient's prescription
for the drug, a new study finds.
This is a newly identified and important patient safety issue,
according to senior author Dr. Thomas Sequist, a physician at
Brigham and Women's Hospital and Harvard Vanguard Medical
Associates, in Boston.
He and his colleagues looked at 1,218 instances in 2009 where
patients' medications were discontinued by Harvard Vanguard
"We found that 1.5 percent of all discontinued medications were
refilled by the pharmacy and that 12 percent of those refilled
medications caused some degree of potential harm to the patients,"
Sequist said in a Brigham and Women's news release.
Harm ranged from serious problems, such as low blood pressure
and possible allergic reactions, to less serious issues, such as
nausea or lightheadedness, according to the study, published in the
Nov. 20 issue of the journal
Annals of Internal Medicine.
Many doctors may incorrectly assume that a patient will remember
to stop taking a drug after they have been taken off it, or that
discontinuing a medication in a patient's electronic health record
is automatically transmitted to the pharmacy, in the same way that
a new prescription is transmitted, the researchers said.
"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," study lead author Dr. Adrienne Allen, associate medical
director of quality, safety and risk at the Boston-area North Shore
Physicians Group, said in the news release.
"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," Allen
The Institute for Safe Medication Practices offers advice for
safe medication use.