Electronic prescriptions allow for providers to enter any free-text directions (Sig) they wish, just as if they were writing a paper prescription. The patient directions are one of the most critical parts of a prescription. It’s a huge safety risk if patients do not understand how to use their prescription or if a pharmacist has to try to interpret what the provider means. In a recent study that analyzed 25,000 electronic prescriptions issued by 22,152 community-based prescribers using 501 e-prescribing software applications, it was found that there was a large number of variations in the electronic prescription directions¹. The quality of the directions also varied greatly.

The study was conducted by Yuze Yang, PharmD, from Surescripts and colleagues, and published online in the Journal of Managed Care & Specialty Pharmacy. Out of the 25,000 e-prescriptions, there were 3,797 unique Sigs concepts identified in the Sig text strings. However, more than half of all patient directions could be classified into just 25 unique Sig concepts. There were large numbers of variation of even what would be considered simple and straightforward directions found. For example, over 800 permutations of words and phrases used to convey "take one tablet by mouth once daily" were identified.

The researchers not only looked at the variations, they also analyzed the Sig text strings for quality-related events which were defined as “Sig text content that could impair accurate and unambiguous interpretation by staff at receiving pharmacies.” The biggest quality issue observed was incomplete Sigs. Prescriptions were commonly missing relevant dosages or administration frequency/timing information. They found that more than one in ten prescriptions contained some sort of quality issue.  Considering the number of electronic prescriptions that are sent and the not only time-wasting potential but possibly catastrophic results that could come from such quality issues, that figure is way too high.

The authors' recommendations for reducing the quality issues and variations include:

• Enhancing e-prescribing application user interfaces and Sig creation tools
• Improving end-user training and usability testing for optimal use of system functionalities
• Adopting and implementing the currently available Structured and Codified Sig format by both prescriber and pharmacy systems to facilitate improved standardization and interoperability

At MDToolbox, patient safety and ease of use for prescribers are two of our main focuses when designing our directions input fields. We offer several options designed to make entering quality directions as easy as possible:

• Sig builder – build complete directions in just a few easy clicks
• Common Sigs – choose from the most commonly used Sigs already available in the system
• Saved favorite directions – prescribers can enter directions that they commonly use and save them as a favorite with a shortcut that can be quickly accessed
• Free-text directions – although free-text directions open it up to possible quality errors, MDToolbox has implemented quality checkers to ensure that free-text directions are not missing any of the information the contributes to many of the quality issues such as “how much” or “how often” the prescription should be used.

MDToolbox is also constantly looking for ways like our quality checkers to enhance these areas even more. Part of the way we do this is by conducting usability tests and end-user trainings in order to get feedback from users and ensure users are taking advantage of the available tools. We share a goal with Surescripts to have zero-error e-prescribing and are continually striving towards this goal.

1. Quality and Variability of Patient Directions in Electronic Prescriptions in the Ambulatory Care Setting https://www.jmcp.org/doi/10.18553/jmcp.2018.17404 

Electronic prescribing (e-Prescribing) has been praised for increasing patient safety by providing clearer prescriptions and reducing medication errors.  Pharmacists no longer have to worry about interpreting the prescriber’s handwriting.  However, it has been found that even with e-Prescribing, more than 10% of prescriptions still contain an error¹.  These errors can be highly dangerous, or even deadly.  Here we list out our top 5 mistakes found in electronic prescriptions (e-prescriptions) and solutions to prevent them.

    1.  Wrong Drug Name or Strength

One of the most dangerous medication errors is prescribing the wrong drug or strength.  E-Prescribing prevents errors that occur from illegible writing, but incorrect medication errors can still occur.  In many e-Prescribing systems, the prescriber selects the drug to prescribe from a lookup.  It is easy to see how a rushed prescriber could make a mis-click and pick the wrong drug or strength.  Additionally, several drugs have similar names.  If prescribers are not careful, they can easily confuse them with each other.  Of all medication errors, the FDA reports that about 10% come from drug name confusion².  Several drugs have different strengths and some have different dosage routes as well.  For example, Ofloxacin is available in both a 0.3% opthamalic solution and a 0.3% otic solution.  Choosing the wrong route could have serious effects.  Selecting the wrong drug, strength, or route could even be fatal.  This is why it is critical that prescribers double check these fields when selecting a drug to e-prescribe. 

A good way to prevent picking the wrong drug name is to use e-Prescribing software that includes tall man lettering to help in selecting look-alike drug names.  These drug names include both lower and upper case letters in order to draw attention to the differences in their names.  For example, two similarly named insulins are listed as NovoLOG and NovoLIN to differentiate between them.

2.  Unclear Directions

The most important part of a prescription for the patient is the directions.  If the patient does not understand how to take/use the prescription, they will not get the intended results and it could be potentially harmful.  A common mistake in e-prescriptions is to write directions that include abbreviations, are incomplete, or that say something generic like “Take as directed.”

The directions must be written out fully in terms that the patient will understand.  They should not include any abbreviations or anything that the pharmacist would need to interpret or rewrite.   While pharmacists may understand the abbreviations, the reality is the busy pharmacist (or rather pharmacist assistant) will quickly re-write it or a computer program will re-write it for them and the translation is many times incorrect.   These mistakes can be fatal.  For example, the FDA reported a patient died when 20 units of insulin was abbreviated as "20 U," and the "U" was mistaken for a "zero"³.  The patient received an incorrect dose of 200 units as a result.

Prescribers must also not assume the patient will remember the directions they gave them orally – Including the full directions in the electronic message to the pharmacist gives the patient written clear directions they can check if they cannot remember what the prescriber told them.  Directions should always include when, how often, and how to take the medication

It is also important to make sure any numbers written in the directions are safely written.  Decimal points can be easily missed.  For example, 1.0 could be quickly read as 10 or .1 could be read as 1.  Prescribers should never include a decimal point and a trailing zero (X.0mg) but should always include a leading zero before a decimal point (0.Xmg).  It is recommended to try to avoid the use of zeroes by using alternative units of measure – for example use “50 micrograms” instead of “0.05 milligrams.” 

3.  Including Directions in the Wrong Place

Another common mistake in e-prescriptions is including direction information in a note or comment field.  The note field is a helpful field that allows prescribers to add additional free text information that is not part of the prescription.  However, this field should never be used for drug name, directions, the number of days, or any important information.  Many prescribers feel the need to include direction information in the note field because their e-Prescribing software does not allow them to enter custom directions.  It is quite challenging to prescribe medications that require tapering or titrations if the prescriber can only enter pre-structured directions.  The problem is most of the pharmacy software does not show the note information on the main dispensing screen and this makes it easy for the pharmacist to miss it.  This can then cause the pharmacist to include incorrect or incomplete directions.  Prescribers sometimes include conflicting direction information in the pharmacy note box as well.  For example a conflict might look like:

Directions:   3 times a day

Free Text Note:  1 GTT Q4 OD – patient has a coupon 

If the pharmacist fills based on directions, they have no idea how much the patient should take three times a day.  If the pharmacist happens to check the free text note field, they now know how much but have conflicting “how often”.  This causes the pharmacist to have to contact the prescriber for clarification and slows down the entire process of e-Prescribing.  This is why it is critical for prescribers to include the full directions in the directions box and only use the pharmacy note field for additional information.  A proper prescription might look like:

Directions:   1 drop in the right ear every  4 hours daily

Free Text Note:  Patient has a coupon

Using e-Prescribing software that allows prescribers to easily free text any custom directions needed, as well as customize their sig and direction lookups, is a great solution for preventing information being placed in the wrong field.  Using these solutions, as opposed to solutions where prescribers can only select pre-structured directions or have to complete complicated extra steps to have detailed directions, is an ideal way to avoid this information from being unseen or conflicting. 

4.  Incorrect Dosage

Another highly dangerous medication error is prescribing the wrong dosage.  It is easy for a prescriber to make a mistake when converting units of measurement or calculating a dose.  These mistakes can result in doses 10 or 100 times the intended amount.  For example, an infant recently died after receiving an overdose of morphine when a 3.5mg dose was given rather than what should have been a 0.35mg dose.  There have been many other cases where these kinds of mistakes have led to fatalities as well.  This is why it is important for prescribers to check and double check the dose they are prescribing. 

A great solution for prescribers is to use an e-Prescribing system that includes dosing references and a dosing calculator at the point of prescribing.   These calculators help prevent calculation errors and give warnings if the calculated doses are too high.  These are especially useful for pediatrics per weight based dosing.  In some systems, like MDToolbox, it will even convert mg per kg to mL automatically if needed for prescribers.  

5.  Wrong Quantity

Prescribers also make the mistake of including a quantity for either the number of days the prescription is for or the amount to be dispensed that is wrong in e-prescriptions.  Prescribing more or less of a medication than intended can have serious effects.   This is why it is important for prescribers to double check the dispense amount and the number of days it should last.  It is important that these amounts do not contradict each other or the directions, otherwise the pharmacist will not know which is the correct amount.

An example of a contradicting prescription:    

Directions:  Take 1 Tablet Daily for 5 days by Mouth

Days Supply:   5

Dispense #:  20

How many should the pharmacist dispense?   Does the patient need to take 20 pills over the next five days?   Or, do they only need to take one daily for five days and thus, only five tablets should be dispensed?  A patient could have serious adverse effects if they take the wrong amount of a prescription.  To ensure safe prescribing, a quality prescription should look like:

Directions:  Take 1 Tablet Daily by Mouth

Days Supply:   5

Dispense #:  5

To further prevent quantity errors, prescribers can use software (like MDToolbox) that helps them with auto calculating these amounts based on the directions and either the selected number of days or dispense number.

In addition to avoiding these mistakes, there are further steps prescribers should take to prevent medication errors.  They should always take the time to double check the complete prescription information before hitting e-Send.  Taking this small extra step can help catch a lot of unnecessary errors.  Prescribers should also make sure that the patient is clear about which prescription they are prescribing for them and the proper way to take/use it.  This way the patient can double check they are receiving the right prescription from the pharmacy and be able to use it as intended.  Prescribers should also use e-Prescribing software that allows them to print patient leaflets, as well as a medication summary that lists the prescriptions to give to the patient.  Medication summaries are a good way to remind the patient which medications were prescribed, how often to take them and which pharmacy they were e-Sent to. 

E-Prescribing continues to improve prescription safety.   We can take patient safety to the next level and minimize medication errors even further with a combination of prescribers following a few simple guidelines, double checking their prescriptions and using patient safety focused e-Prescribing software.   

If you have comments or suggestions for our blog or would like to learn more about MDToolbox’s e-Prescribing solutions we would love to hear from you!  Please leave a comment below, use our contact form or email us any time at info@mdtoolbox.com. 

1. Nanji KC, et al "Errors associated with outpatient computerized prescribing systems" J Am Med Inform Assoc 2011; DOI:10.1136/amiajnl-2011-000205.
2. Rados C. “Drug name confusion: preventing medication errors.” FDA Consumer Magazine. 2005;39. www.fda.gov/fdac.
3. "Strategies to Reduce Medication Errors: Working to Improve Medication Safety." U.S. Food and Drug Administration, 12 Apr. 2013. Web. 09 Jan. 2014.

One of the biggest draws of e-Prescribing is increasing safety by providing alerts for adverse reactions.  E-Prescribing systems can show warnings to prescribers for drug-drug, drug-allergy, drug-condition, and many other potential interactions.  However, these alerts actually become a problem if they are shown too often.  Prescribers start to have what is known as Alert Fatigue and completely ignore some or all of these warnings.  If messages are constantly popping up, a prescriber is likely to pay less attention to them and simply override them to continue with their workflow.  Studies have even shown as much as 95 percent of drug interaction alerts and 77 percent of drug allergy alerts are disregarded by doctors. 

This would not be such a huge issue if prescribers were only overriding low priority alerts.  However, they are overriding high priority alerts as well.  The problem comes from too many low priority and irrelevant alerts being shown.  Imagine a doctor first receiving a low priority alert, then an alert irrelevant to the patient, then another lower priority alert, and so on.  Doctors become so overwhelmed with alerts that they simply override all of them without taking notice of what they are, including those with the potential to prevent serious harm to patients.  A recent study published in the Journal of the American Medical Informatics Association looked at the appropriateness of overridden alerts.  Appropriate was defined as having the potential to prevent serious harm.  The study found that 53% of all overridden alerts were appropriate¹. 

Reducing Alert Fatigue

It seems like a simple concept: To reduce alert fatigue, the number of alerts needs to be minimized. With so much alert information available, the challenge comes from deciding which alerts should be shown and which are less important.  E-Prescribing vendors are also faced with solving how to display the important alerts in a manner that doesn’t diminish work-flow. 

Drug-drug and drug-allergy interaction checking is a criterion in both Meaningful Use Stage 1 and Stage 2.  The 2014 Meaningful Use HIT Certification Program, approved by the Office of the National Coordinator for Health Information Technology (ONC), defines that drug-drug and drug-allergy alerts must both be automatically shown at the point of prescribing.  The drug-drug alerts shown must also be adjustable by severity level².   

This means that certified products should, at a minimum, be including the ability to minimalize minor drug-drug interaction alerts.   This, however, does not cover severity level per drug-condition or drug-allergy alerts.  A minor intolerance allergy alert should be treated different than a major interaction that can cause serious harm or even death. 

The ONC has also created a list of the most critical drug-drug interactions (separate from the Meaningful Use program).  It has recommended that this list of 15 interactions be included in all prescribing systems and always generate an alert that cannot be turned off.  Some have suggested that these alerts should also require more to override them then the standard alerts, such as a required written reason.  It was also suggested that including these 15 alerts be a criterion for Meaningful Use of drug-drug interaction alerting.  However, this list is said to only be responsible for less than 1 percent of drug interaction alerts in some systems.  What about the rest of the alerts? 

Taking it a step further - Eliminating Alert Fatigue

In order to maximize patient safety and prescriber workflow, e-Prescribing systems need to go above and beyond the Meaningful Use Criteria.  There are 3 main points that need to be addressed to work towards the ultimate goal of eliminating alert fatigue:

      1. Selecting the Important Alerts

The importance of alert types varies from specialty to specialty and even from doctor to doctor.  This is why it is important for e-Prescribing vendors to have the ability to allow each prescriber to set their own customizable alert levels.  Each prescriber should be able to select for each alert type (not just drug-drug) whether they want to see all of the available alerts, only the highest alerts, or somewhere in between in order to maximize the effectiveness of the alerts. 

       2.  Displaying Alerts Without Causing “Fatigue”  

It is important to categorize all alerts by their severity level and display this information in a clear and easy to understand format.  If a prescriber has selected to see all alerts, it is still significant for them to know which are the highest alerts.  Color-coding alerts so that for example, red is the highest, is a good way to make each alert level clear to the user.  Alert fatigue can also be reduced by including all alerts for a given prescribing event together.  Instead of having several individual alerts popup one after another, all alerts should be displayed in one window with the highest level alert displayed at the top.   Review, overriding, or re-evaluation should never involve more than one or two clicks to continue with prescribing workflow.

3.  Creating Smarter Alerts 

A lot of e-Prescribing systems categorize each alert by level of risk per one drug interacting with another drug, but what about interaction concerns per age, weight, or condition that increase the risk?  At MDToolbox, we have taken it a step further and allow prescribers to create decision support interventions at the point of prescribing that can take into account other factors (like age, weight) when determining alert display.  We also include optional dosing references, alerts and calculators to further aid in “smart alerts”. 

Instead of being viewed as a hindrance in the prescribing workflow, alerts should be viewed as an important safety aid.  We hope that by reducing alert fatigue, the true effectiveness of prescribing medications with an alert system will be realized. 

1. Nanji KC, Slight SP, Seger DL, et al. Overrides of medication-related clinical decision support alerts in outpatientsJ Am Med Inform Assoc Published Online First: 28 October 2013. doi:10.1136/amiajnl-2013-001813
2. Office of the National Coordinator for Health Information Technology (ONC) - Test Procedure for §170.314 (a)(2) Drug-drug, drug-allergy interaction checks:   14  December, 2012.  http://www.healthit.gov/sites/default/files/170.314a2drug_interaction_checks_2014_tp_approvedv1.2.pdf

E-prescribing makes it quick and easy for a doctor to prescribe a medication to a patient.  However, doctors need to take extra precautions to ensure that they are not prescribing unnecessary medications too quickly. 

Prescription drug abuse is a fast growing problem in America.  According to a study by the National Institute on Drug Abuse, approximately 7 million Americans abuse prescription drugs¹.  Furthermore, the CDC reported that in 2010, over 22,000 drug overdose deaths involved pharmaceutical drugs².  While the prescription medications can be obtained several unlawful ways (stealing someone else’s prescription or getting them through a drug dealer), a majority of them are obtained through prescriptions written directly for the drug abuser.  Drug seekers will “doctor shop” to find a doctor (or multiple doctors) who is willing to write them a prescription for their chosen drug. 

What Is Being Done?

49 states (all except Missouri) have put a Prescription Drug Monitoring Program (PDMP) in place.  These are electronic databases that prescribers can access to check a patient’s controlled substance prescription history within the state.  These are valuable tools that can help reduce prescription drug abuse.

Surescripts®, the nation’s largest e-Prescribing hub, also offers access to some Nationwide Pharmacy Fill History and Pharmacy Benefit Managers (PBM) claim history.  For e-Prescribing software systems that certify on this feature and prescribers that take advantage of it, this is an invaluable tool.

Is It Enough?

These tools can only help if they are actually used.  Checking these databases is voluntary in most states.  The Tampa Bay Times did an investigation in Florida on the actual use of their drug monitoring program.  They found that out of 48 million controlled substance prescriptions written, prescribers had only checked the database before writing 2 percent³.   There are only two states that have taken lead in making the use of these databases mandatory.  In August, New York put into effect the I-STOP law which requires prescribers to check their state database before prescribing controlled substances.  Tennessee also has a similar law in effect. 

In addition to actually using the databases, another key component to their effectiveness is that they provide current information.   One more significant part of New York’s I-STOP law is that it requires real-time reporting by pharmacists dispensing prescriptions.  The reporting requirements vary from state to state with only a couple requiring real-time reporting, some requiring reporting done within 24 hours and others only requiring monthly reporting. 

The PDMPs also vary from state to state as to which agency houses the database, which controlled substances are reported, who is required to submit data, and how noncompliance is enforced.  Some states are able to share data with other states while others are not.

And while e-Prescribing systems that offer access to the Surescripts® claims and fill history do allow for a nationwide accessible database, not all pharmacies and PMBs are in the network.  More importantly, not all prescribers take the time to pull the history even when they have the tool.

While Surescripts® and many states have taken a step in the right direction, in order to be as effective as possible in reducing prescription drug abuse, a database needs to:

• Be National – Each state having their own database is not the most effective model.  Drug abusers can easily cross state lines or even move to a new state to get more prescriptions.  The drug database information needs to be available nationwide.   An e-Prescribing Vendor wanting to give their prescribers access to all data would currently need to integrate with 49 PDMP systems and Surescripts®.

• Be Mandatory – Every prescriber should be required to check the drug database.  The information is of no use if it isn’t seen.

• Require pharmacy real-time reporting – Having the most current data available will prevent drug abusers from being able to get prescriptions from multiple pharmacies. 

• Include all prescriptions – Schedules of drugs can be changed and drugs that were once non-controlled substances become controlled substances.  A complete history of all prescriptions would be most beneficial to prescribers.  This information is not only helpful in fighting drug abuse, it can aid in the overall quality of patient care. 

• Be Standardized and Interoperable – Prescribers are much more likely to make use of the data if it is part of their normal workflow.  Having to login to a separate database in a new window is a hassle.  However, if the data is available in a standardized format that can be integrated with a prescriber’s current e-Prescribing solution it becomes much more effective.  While a Nationwide centralized database would allow for prescribers (and technology vendors) to be able to have one complete picture, interoperability between the PDMPs and Health Systems becomes important until that can happen.  Moving in that direction, the Office of the National Coordinator for Health Information Technology (ONC) just launched the PDMP & Health IT Initiative last week.  It aims to create standard methods for exchanging the data between PDMPs and health systems.  As described in the challenge statement, “There are a lack of common technical standards and vocabularies to enable PDMPs to share computable information with the EHR that providers can use to support clinical decision-making.”⁴

What Can Prescribers Do In The Mean Time?

Until there is one central database or interoperability between all e-Prescribing systems and PDMPs, prescribers should ensure they use their state systems and in addition, that they are using e-Rx programs that make national drug usage information available.  Programs like MDToolbox have access to the Surescripts® Nationwide Medication History through participating PBMs and pharmacies.   While this is still limited to the PBMs and pharmacies in the network and not mandated, it does give prescribers one more tool to stop abuse and prescription shoppers.  

1. "Topics in Brief: Prescription Drug Abuse" NIDA, December 2011.
2. “Opioids drive continued increase in drug overdose deaths,” CDC, February 2013.
3. Cox, John W. “Florida drug database intended to save lives is barely used by doctors.” Tampa Bay Times 6 Oct. 2012. http://www.tampabay.com/news/health/florida-drug-database-intended-to-save-lives-is-barely-used-by-doctors/1255062
4. Prescription Drug Monitoring Program (PDMP) & Health IT Integration Initiative, Office of the National Coordinator for Health IT http://wiki.siframework.org/PDMP+%26+Health+IT+Integration+Charter+and+Members

Our post last week covered the top 5 benefits of using e-Prescribing software for providers.  If you missed it, check it out here.  This week we focus on the benefits as they relate to patients.  

5) Patient Education Materials

Most e-Prescribing software includes drug reference information, including leaflets that can be printed and given to the patient (or electronic).  These leaflets are often available in several different languages, as well as adult and pediatric forms.  They include warnings, possible side effects, how to take the drug, and any other important information the patient needs to know about the drug.  Some products, including MDToolbox, also provide patient education information on patient conditions that can be printed and given to the patient as well.  

4) Compliance

An estimated 20% of all paper prescriptions are never filled ¹.  Eliminating the need to drop off the prescription at the pharmacy and reducing wait times aid in patient compliance.  Some providers may worry that the patient may forget to pick up a prescription that was e-Sent.  However, software like MDToolbox provides an auto print out of a “Prescription Receipt” that the prescriber can hand to the patient so they remember to go pick it up, as well as which pharmacy it was e-Sent to.  The print out also includes the prescription directions so that the patient is clear on how the prescription should be taken.

3) Saves Patients Time

Using e-Prescribing software significantly reduces the time the patient has to wait at the pharmacy and in most cases, the prescriptions are ready for the patient as soon as they get to the pharmacy.  Multiple trips to the pharmacy are eliminated and time spent waiting for physicians to reply to refill requests is reduced as well.

2) Saves Patients Money

Through most e-Prescribing programs, prescribers have access to a patient’s formulary information at the time of prescribing.  This allows the prescriber to view which drugs will be covered for the patient and which ones are not.  Many times co-pay information is also available.  This way the prescriber can pick the lowest cost drug available for the patient.  A study by Decision Resources found that 75% of the doctors surveyed said when they e-Prescribe they pay more attention to the costs for their patients².

1) Improves Patient Safety

We stated it last week, but it’s worth stating again (and again) because it is so important: e-Prescribing software greatly improves patient safety. 

Patients who see a provider who uses e-Prescribing do not have to worry about the pharmacist being able to interpret the prescriber’s handwriting.  They can be sure that the prescription the prescriber intended to write is readable in a standard, clear format by the pharmacist.  MDToolbox even uses tall man lettering, a way of distinguishing look-alike drug names, to maximize the amount of medication errors reduced. A survey by the Institute for Safe Medication Practices (ISMP) reported that 64% of all respondents stated that the use of tall man letters had prevented them from providing the wrong medication³.  

Through software systems like MDToolbox, prescribers can even access the patient’s medication history available from pharmacies and PBMs, so even if a patient forgets to report a medication they are currently taking, the prescriber will still have a record of it.  Having a complete, current medication list is important so prescribers can check for harmful and even possibly lethal drug interactions.  Prescribers can check against the patient’s records not only for drug-drug interactions, but also drug-allergy, drug-condition, duplicate therapy, body weight, age, and correct dosing. 

It’s clear from all of these benefits, e-Prescribing is a great tool to aid providers in giving patients the safe, affordable care they need.  

1. Koroneos, George, "Hard of (Ad)hering", Pharmaceutical Executive, August 1, 2008
2. Moore, Roy, “E-Prescribing and Electronic Health Records: Impact of Technology on Prescribing for Hypertension and Diabetes”, Decision Resources, February 2013
3. Institute for Safe Medication Practices (ISMP) Survey on tall man lettering to reduce drug name confusion. ISMP Med Saf Alert! 2008;13(10):4.