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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 resistance.

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 Prescription Month"

  • 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 vendors).
  • 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 refill.
  • 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.

References

  1. Levenson D. Keeping track of prescriptions. AHA News. 2000;36:5.
  2. Viessides M. Nearly half of discharge orders changed by pharmacists at community hospital. Pharm Pract News. 2000 (May):1.
  3. Goldman B. The news on the street: prescription drugs on the black market. CMAJ. 1998; 159:149-150.
  4. Sansone RA, Gaither GA, Righter EL. Prescription diversion among patients in a family practice clinic [letter] Arch Fam Med 2000;9:587.
  5. Ceaser S, Wurtz R. "Leftover antibiotics in the medicine cabinet. Ann Intern Med. 2000;133:74.
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