Communication, workflow vulnerabilities cause errors | Wbactive

Pharmacists should involve patients and investigate system fixes to avoid missed drug interactions

A patient called a specialty pharmacy to schedule delivery of secukinumab (Cosentyx), a monoclonal antibody that blocks IL-17A. Secukinumab is used to treat ankylosing spondylitis, axial spondyloarthritis, enthesitis-related arthritis, plaque psoriasis, and psoriatic arthritis. A technician set up the delivery and placed the order in the pharmacist’s verification queue within the dispensing software.

During a telephone conversation with the pharmacist, the patient stated that she had started taking tofacitinib (Xeljanz) samples from the provider the previous month. Tofacitinib is a Janus kinase inhibitor used in ankylosing spondylitis, polyarticular juvenile idiopathic arthritis, psoriatic arthritis, rheumatoid arthritis, and ulcerative colitis. The use of tofacitinib in combination with biologic disease-modifying anti-inflammatory drugs, biologic therapies (for ulcerative colitis), or potent immunosuppressants such as secukinumab is not recommended. The pharmacist attempted to contact the provider to confirm the treatment plan, but the provider was not immediately available so the pharmacist had to leave a message.

In the meantime, another pharmacist saw and verified the prescription in the verification queue. The order was then filled out and sent to the patient. When the dispensing error was discovered, the pharmacy called the vendor’s office again. The pharmacy confirmed that the patient should no longer take secukinumab.

Decisive Factors

The pharmacy identified many factors that contributed to this error: (1) the provider did not inform the pharmacy that the patient should stop taking secukinumab or that the patient had started taking tofacitinib samples; (2) the patient was unaware that he should stop taking secukinumab; (3) 2 separate pharmacists worked on this order: one spoke to the patient and the other reviewed the order; (4) the second pharmacist did not realize that the secukinumab should not be filled because the first pharmacist did not communicate or note so; (5) there was a delay in resolving the issue and confirming the correct treatment plan with the provider because the first pharmacist was unable to speak to the provider immediately; and (6) although the pharmacist who spoke to the patient entered tofacitinib into the patient’s medication history in the dispensing software, this did not trigger a DUR (Drug Utilization Review) alert for dual therapy or drug-drug interaction since the prescription already occurred in the DUR/Review queue.

Risks of using drug samples

As seen in the case above, there can be disruption in communication between prescribing physicians and pharmacies when dispensing samples to patients, leaving pharmacies without the necessary information about patients’ drug therapy. In addition, drug samples are often provided without allergies, contraindications, computer screening for drug interactions and dual therapies, and independent second person review. Patient education may be limited or narrowly focused, drug recalls may be overlooked, and samples may even be expired by the time they are made available to patients.

Recommendations for Safe Practices

To avoid these types of errors, explore ways to electronically tag or mark that a prescription is awaiting a prescribing physician and/or patient follow-up. Ideally, pharmacy computer systems would not allow prescriptions to be dispensed until the issue was marked as resolved. Another option suggested by the Institute for Safe Medication Practices is to explore ways to move orders out of the workflow if there’s an issue that’s preventing another team member from completing the order. It’s important to think about potential implications (e.g. where the order will remain if it is removed from the workflow, how pharmacists will track where the prescription is in the process, and which pharmacist will be responsible for final tracking) and perform an assessment such as a failure mode and impact analysis to identify potential failure points in the redesigned workflow. Establish a process to communicate issues with orders, including adding system notes or communicating directly with co-workers. Update the patient profile with any new drugs the patient is taking so that the pharmacy’s computer system alerts the pharmacist to drug interactions and duplicate therapy if the prescription has not yet moved to the DUR/verification queue. Test the pharmacy’s computer system at various stages of the workflow to determine if DUR alerts are triggered when a patient’s medication history is updated.

Encourage providers to report therapy changes, including discontinued or new therapies, to the pharmacy. The CancelRx transaction in electronic prescription systems can be used to notify the pharmacy when a medication is being discontinued.

When using drug samples, special care must be taken to protect patients from harm and medication errors. Get help from patients by asking them to discuss or show them drug samples they have received. Pharmacy staff can then enter medications into the pharmacy system so pharmacists can perform the important DUR checks. Finally, it’s a good idea to advise patients to check expiration dates on drug samples.

About the author

Michael J. Gaunt, PharmD, is Senior Director of Error Reporting Programs and Editor at the Institute for Safe Medication Practices (ISMP) in Horsham, Pennsylvania. He also acts as editor of the monthly magazine Safety Warning for ISMP Drugs! Community/Ambulatory Care Newsletter.

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