Copying an Old Prescription May Lead to Trouble

Copying old prescriptions can expedite the dispensing process, but be careful when editing and verifying new or updated prescriptions. The Institute for Safe Medication Practices continues to receive reports of dispensing errors occurring when a previous prescription was copied in a pharmacy computer system.

Case Examples

In one case, a pharmacy dispensed the incorrect strength of hydrocodone/acetaminophen. The error was discovered when investigating why the patient needed to have the prescription filled several days early. The pharmacy had incorrectly dispensed hydrocodone/acetaminophen 5 mg/325 mg. Upon discovery, the provider was contacted and informed of the error. A new prescription for hydrocodone/acetaminophen 7.5 mg/325 mg was then filled. The error was thought to have been caused by copying an old prescription from the previous month without the correction in strength being made.

Another case involved a patient with a new prescription for oxycodone 5 mg. A few months earlier, this patient had received a prescription for oxycodone 30 mg. To expedite the dispensing process, the pharmacist chose to copy the previous oxycodone 30 mg prescription but failed to change the dosage strength. The patient received oxycodone 30 mg and used this strength for a month. The patient’s physician discovered the error and notified the pharmacy. The pharmacy’s analysis of the event found that the pharmacist conducted the final prescription verification immediately after he completed the order entry and filled the prescription, which limited the effectiveness of the checking process.

In a third case, a community pharmacy dispensed Adderall XR 20 mg (dextroamphetamine sulfate, dextroamphetamine saccharate, amphetamine sulfate, and amphetamine aspartate monohydrate extended release) to a patient instead of the prescribed Adderall XR 10 mg. The patient discovered the error at the point of sale when he looked at the pharmacy label. The patient had previously taken Adderall XR 20 mg, but his doctor was switching him to Adderall XR 10 mg. One of the contributing factors was the computer system’s functionality, which allowed the individual conducting order entry to copy a previous prescription for the same drug.

In a recent case, a patient received a new prescription for chlordiazepoxide 10 mg. The patient had previously been taking chlordiazepoxide 25 mg. The pharmacy technician generated a “new from old” prescription when the new one was dropped off but did not change the capsule strength to 10 mg from 25 mg. As a result, chlordiazepoxide 25 mg was dispensed. The prescriber discovered the error and contacted the pharmacy to ask about the lower dose of medication.

Copying and Placing a Presciption On Hold

The copy function can also be used when placing a prescription on hold to fill later. When the computer system’s prescription copy or linking functionality is used in these cases, there is a risk that the order entry verification may be skipped or not done with the same attentiveness. The pharmacist may think it will be double-checked when the prescription is eventually processed and dispensed to the patient.

Safe Practice Recommendations

Evaluate the computer system’s prescription copy or linking functionality. Some
systems may prompt users to link new prescriptions to those already on patient profiles. Although this functionality can increase order entry efficiency, any changes on the new prescription may be missed. If this functionality is used, review the workflow, process, and prompts when copying or linking to old prescriptions. Consider ways to have the computer system guide the individual conducting order entry in verifying whether each piece of information, such as drug name or strength, directions, quantity, strength, or suffix, on the new prescription matches the one already on the patient’s profile before accepting the copy. Even if the computer system cannot incorporate this change, the manual process used to verify prescriptions should include these additional steps. Educate practitioners about the importance of verifying each piece of information.

Additionally, when using this functionality to place a prescription on hold, it is critical that the order entry undergoes the same verification process used when a prescription is dispensed. This includes rechecking the order entry by comparing the prescription information entered in the computer system with that on the original prescription. When the prescription is dispensed, verification against the original prescription or its scanned image should be done again. Final verification should include a review of the patient’s profile and a prospective drug use review. Engaging the patient as a final check at the point of sale also can help catch errors.

About The Author

Michael J. Gaunt, PharmD, is a medication safety analyst and the editor of ISMP Medication Safety Alert! Community/Ambulatory Care newsletter at the Institute for Safe Medication Practices in Horsham, Pennsylvania.