There is much to talk about during
NCPIE's "Talk About Prescriptions Month!"
From the October 18, 2000 issue
October is Talk About Prescriptions Month, sponsored
by the National Council on Patient Information and Education
(NCPIE). ISMP joins NCPIE in promoting this year's theme,
"Educate Before You Medicate: Knowledge is the Best Medicine."
Yet, following such sound advice has become increasingly difficult
for both patients and healthcare professionals. Even keeping
track of prescribed therapy has become a formidable task.
A study of elderly patients taking four or more prescribed
drugs showed that primary care physicians could not accurately
list all the medications taken by 75% of their patients, and
disagreed with 86% of the drug schedules.1 We've
also received reports from practitioners who are concerned
that drugs prescribed upon hospital discharge may not correlate
with inpatient and preadmission therapy. This can lead to
possible omissions, duplicate therapy, unrecognized drug interactions,
and readmissions from adverse drug reactions. In fact, a recent
article in Pharmacy Practice News noted that, in a
community hospital, pharmacists needed to change nearly half
of the discharge orders.2
It has also been a challenge to keep patients well informed
about their drug therapy. Managed care companies may regularly
change formulary drugs within drug classes. This had led to
reports of patients accidentally taking both the new and discontinued
medications. A change in drug therapy upon hospital discharge
has likewise led to confusion regarding previously prescribed
drugs. The risk of duplicate or unintended therapy is compounded
because patients may be reluctant to discard older, sometimes
expensive, medications on the chance of later being switched
back to the drug. The misuse of prescribed drugs has also
been problematic. The National Household Survey on Drug Abuse
found that 1.4% of the general public acknowledged using prescription
drugs not prescribed for them.3 Another study showed
that 6% of family practice patients had shared prescription
drugs with family or friends.4 Likewise, self-treatment
with leftover antibiotics is prevalent. A random survey showed
that 26% of respondents had saved antibiotics from prescriptions
not completed;5 of those, half had taken the remaining
antibiotics later without consulting a healthcare professional,
and some had given the antibiotics to others. Such practices
could lead to errors, drug or allergic reactions, and antibiotic
Filling prescriptions can also be problematic. Patients may
not realize that they should fill all prescriptions at the
same pharmacy for proper screening. In other cases, reimbursement
systems may require patients to obtain chronic drugs from
mail order pharmacies and acute care drugs from local pharmacies.
We recently heard of an error where a retail pharmacy automatically
sent a patient a refill for verapamil, which had been discontinued
during the patient's recent hospitalization. Unfortunately,
the patient took the drug along with other cardiac medications
and had to be hospitalized after losing consciousness. Finally,
patients may not fill their prescriptions because they have
exhausted their prescription limits or have no coverage. One
physician told us about a patient who was too embarrassed
to tell him that she could not fill her prescription for an
antihypertensive medication until January, when her insurance
limits renewed. Because her blood pressure was elevated, the
physician increased the dose. Then in January, when the patient
again had insurance coverage, she filled the prescription
at the higher dose and suffered a significant hypotensive
episode. If patients tell their physicians that they have
limited ability to fill prescriptions, samples may be dispensed,
which often do not include written directions as found on
prescriptions filled by a pharmacy.
Talking points for "Talk About
- To keep track of prescribed therapy in the physician's
office, design a drug profile to list all prescribed therapy
(date, drug, dose, directions, number dispensed, number
of refills), over-the-counter (OTC) drugs, vitamins, herbal
and other alternative therapy, allergies, and height and
weight. The profile could also include special monitoring
prompts. Review and update the drug profile at each visit.
(If electronic handheld devices are used for prescribing,
they will also track patient prescriptions. See our web
site at www.ismp.org for a white paper listing names of
- If a patient calls for a refill, use the drug profile
as a ready source of information to evaluate underuse or
overuse of the drug and the need for reassessment before
- If the insurer requires a therapeutic change or prescribed
therapy differs from that previously prescribed (e.g., at
hospital discharge), provide the patient with written instructions
about which drug is being replaced by the newly prescribed
drug. Instruct the patient to discard the discontinued medication.
- Emphasize the danger in keeping leftover medications,
self-medicating at a later time, and sharing any prescription
medication with others.
- Ask the patient, family or caregiver to bring in all current
medications, vitamins, herbal products and other alternative
medications at each office or hospital visit for verification.
- To facilitate accurate drug therapy upon hospital discharge,
obtain information about prescription and OTC drugs taken
at home. Post a daily, pharmacy computer-generated medication
summary on each patient's chart (listing current and discontinued
medications) for physicians to reference, along with the
preadmission drug list, when prescribing drugs at discharge.
- Establish criteria for an automatic consult to a pharmacist
to educate hospitalized patients at risk (e.g., complex
medication regimens, and patients being discharged on five
or more prescription drugs).
- Tell patients to take all dispensed doses of antibiotics
unless directed by the physician to discontinue the drug.
- Remind patients to obtain all prescriptions at the same
pharmacy whenever possible and alert their pharmacist to
any prescriptions dispensed elsewhere.
- Advise patients to request a phone or mail alert before
accepting automatic refills. If patients have questions
about continuing the medication, instruct them to ask the
pharmacist to call their primary care doctor.
- If samples are dispensed to patients, be sure that labels
with patient specific directions and indications for use
are attached to the sample container. Providing patients
with package inserts is not sufficient.
- Many other practical tips for patients about safe medication
practices can be found on our web site at www.ismp.org.
or through NCPIE at www.talkaboutrx.org.
- Levenson D. Keeping track of prescriptions. AHA News.
- Viessides M. Nearly half of discharge orders changed by
pharmacists at community hospital. Pharm Pract News.
- Goldman B. The news on the street: prescription drugs
on the black market. CMAJ. 1998; 159:149-150.
- Sansone RA, Gaither GA, Righter EL. Prescription diversion
among patients in a family practice clinic [letter] Arch
Fam Med 2000;9:587.
- Ceaser S, Wurtz R. "Leftover antibiotics in the medicine
cabinet. Ann Intern Med. 2000;133:74.