Evaluation of the frequency of dispensing electronically discontinued medications and associated outcomes

To determine if outpatient pharmacies of an academic medical center inadvertently dispense discontinued medications and, if so, if these inadvertently dispensed prescriptions contribute to subsequent hospital admissions and patient harm.

This was a single-center retrospective chart review. Prescription billing data were analyzed for electronic prescriptions for hypotensives, hypoglycemics, anticoagulants, antiplatelets, and statins picked up from 3 outpatient pharmacies within the health system over a period of 1 year. Prescriptions must have been written by a Michigan Medicine health system provider and were excluded if they were written, faxed, or phoned in. Timestamp of pick-up from the pharmacy was compared with timestamp of prescription discontinuation within the electronic health record (EHR). If the prescription was discontinued before pick-up, timestamps were also assessed to determine if the prescription order was discontinued in the EHR before final pharmacist verification. If a prescription was found to be picked up after it was discontinued, the patient chart was reviewed to determine if he or she was admitted within 30 days of the pick-up date.

Overall, 10,649 individual electronic prescriptions met inclusion criteria. Of these, 526 (4.94%) were picked up after the prescription order was discontinued in the EHR. The prescription was discontinued before final pharmacist verification for 287 (54.56%) of these prescriptions. Three of these inadvertently dispensed prescriptions could have contributed to hospital admission 30 days after pick-up for 3 individual patients.

Electronic prescriptions that have been discontinued within the EHR continue to be dispensed to patients in the outpatient pharmacy setting. These inadvertently dispensed prescriptions have the potential to cause patient harm.