Summary shows safety events were reduced with pharmacy notification of discontinued prescriptions

The study aimed to highlight problems with the correct delivery of interrupted drugs, which increases the risk of drug safety events.

A summary presented at the American College of Cardiology Quality Summit Virtual showed that there are several methods that can be used to alert community pharmacy staff to canceled medications, potentially avoiding nearly 200 safety events over 2 months.

The study aimed to highlight problems with the correct delivery of interrupted drugs, which increases the risk of drug safety events. This problem continues to grow as many prescriptions are sent to pharmacies through electronic health record systems.

“Currently, there is no ideal way to notify a pharmacy that a clinician has discontinued treatment for a patient, which often results in discontinuation of treatment or a repeat of an incorrect dose and creates a confusion for the patient, ”said study author Jeffrey A. Goss, FNP -c, MSN, APP director of heart failure for Intermountain Healthcare in Murray, Utah, in a press release. “Patients are at risk of taking a drug that is no longer indicated or at the wrong dose, which has important indications for drug safety.”

The Intermountain Healthcare team attempted temporary solutions, including clinical staff personally calling the pharmacy to alert them of new medication changes and requesting that the medication be removed from the patient profile. Additionally, clinicians were asked to document medication changes in the “comments” box of an electronically sent prescription to further alert pharmacy staff to medication changes, according to the study.

Over a 60-day period, 16 advanced practice providers from the Heart Failure / Advanced Transplant Team at Intermountain Medical Center used CancelRx to notify the pharmacy of a drug discontinuation. Throughout the trial, they tracked a total of 558 discontinued drugs, received 359 error messages, and made 148 phone calls to pharmacies. There were 196 potential safety events avoided using CancelRx and phone calls during the trial, with the 5 pharmacies including Intermountain Pharmacies (210), Smiths (117), Walgreens (38), Costco (25) and CVS (23).

“Effective communication between the clinician and the pharmacy is essential to ensure that patients receive only the medications they need. In addition to the safety implications, it will also reduce the likelihood of a patient purchasing an interrupted prescription, resulting in savings for patients and insurers, ”said study author Steven Metz, PharmD, BCPS, Advanced Clinical Ambulatory Care Pharmacist, Intermountain Healthcare in Murray, Utah, in press release.

The study authors recommend that healthcare systems review the way their electronic medical record systems interface with their local pharmacies to avoid one less potential area of ​​error in patient care.


Notifying pharmacies of interrupted prescriptions helps reduce safety events. American College of Cardiology. September 29, 2021. Accessed October 1, 2021. – reduce-security-events

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