Communication, Workflow Vulnerabilities Cause Errors

A patient called a specialty pharmacy to set up 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 delivery and placed the order in the pharmacists’ verification queue within the dispensing software.

When speaking to the pharmacist over the phone, the patient indicated she had started taking tofacitinib (Xeljanz) samples from the provider the previous month. Tofacitinib is a Janus kinase inhibitor used for ankylosing spondylitis, polyarticular-course juvenile idiopathic arthritis, psoriatic arthritis, rheumatoid arthritis, and ulcerative colitis. Tofacitinib is not recommended for use in combination with biologic disease modifying antirheumatic drugs, biologic therapies (for ulcerative colitis), or potent immunosuppressants such as secukinumab. 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, a different pharmacist saw the prescription in the verification queue and verified it. The order was then filled and shipped to the patient. When the dispensing error was discovered, the pharmacy called the provider’s office again. The pharmacy confirmed that the patient was no longer supposed to be taking secukinumab.

Contributing 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 they should no longer be taking secukinumab; (3) 2 separate pharmacists were working on this order: one spoke with the patient and the other verified 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 this; (5) there was a delay in resolving the issue and confirming the correct treatment plan with the provider because the first pharmacist was not able to speak with the provider right away; and (6) although the pharmacist who spoke with the patient entered tofacitinib into the patient’s medication history in the dispensing software, this did not prompt a drug utilization review (DUR) alert for duplicate therapy or the drug-drug interaction because the prescription was already in the DUR/verification queue.

Risks with Use of Drug Samples

As seen in the case above, breakdowns in communication between prescribers and pharmacies can occur when samples are given to patients, leaving pharmacies without needed information about patients’ drug therapy. In addition, drug samples are frequently provided without allergies, contraindications, computer screening for drug interactions and duplicate therapy, and an independent check by a second individual. Patient education may be limited or narrow in scope, drug recalls may be overlooked, and samples may even have expired when provided to patients.

Safe Practice Recommendations

To help prevent this type of error, explore ways to electronically flag or mark that a prescription is awaiting a prescriber 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 is an issue to prevent another team member from completing the order. Be sure to think through potential implications (eg, where the order will reside if removed from the workflow, how the pharmacists will track where the prescription is in the process, and which pharmacist is responsible for finalizing any follow-up) and conduct an assessment, such as a failure mode and effects analysis, to identify potential failure points in the redesigned workflow. Establish a process to communicate issues with orders, including adding system notes or direct communication with colleagues. Update the patient’s profile with any new drugs the patient is taking, so the pharmacy computer sys-tem will alert the pharmacist to drug-drug interactions and duplicate therapy if the prescription has not yet moved to the DUR/verification queue. Test the pharmacy computer system at various stages of the workflow to determine whether DUR alerts will fire 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 prescribing systems can be used to communicate to the pharmacy the discontinuation of a medication.

Special care must be taken to keep patients free from harm and medication errors when using medication samples. Enlist the help of patients by asking them to discuss or show medication samples they have received. Pharmacy staff members can then enter the medications into the pharmacy system so pharmacists can perform the important DUR checks. Finally, it is a good idea to advise patients to check the expiration dates of any sample medications.

About the Author

Michael J. Gaunt, PharmD, is senior director for error reporting programs and editor at the Institute for Safe Medication Practices (ISMP) in Horsham, Pennsylvania. He also serves as the editor of the monthly ISMP Medication Safety Alert! Community/Ambulatory Care newsletter.