Closing the Communication Gap Between Prescribers and Pharmacists to Decrease Medication Safety Risks

A gap in relaying a prescription change can lead to an adverse drug event

When a medical provider discontinues a patient’s medication, the prescription change is updated in the provider’s electronic health record (EHR). However, this update is not always reflected in a pharmacy’s medication list for the patient, which can lead to erroneously filling prescriptions that are no longer prescribed by their provider. Communication of medication discontinuation between prescribers and pharmacies is critical to medication management and preventing adverse drug events (ADEs). Dr. Samantha Pitts, faculty in General Medicine at Johns Hopkins, was driven by her experience as a prescribing provider and her recognition of the safety risk for patients and sought to explore how an existing tool—CancelRx—could be expanded to close the communication gap between providers and pharmacists.

Communication is key to ensuring medication safety

CancelRx is an e-prescribing tool that electronically communicates medication discontinuation updates in the provider’s EHR to pharmacies. The tool allows pharmacists to have patients’ current prescription information and notifies them when a provider discontinues a patient’s prescription. Dr. Pitts sought to identify how this tool directly impacted dispensing after the discontinuation of medication, and to develop strategies to optimize implementation of CancelRx in the Johns Hopkins Health System. Through observation and key informant interviews, the research team worked to understand how staff were using the tool and where there might be information needs or gaps.

“Realizing that there was a gap in communication between me—as a prescriber—and pharmacy staff was a motivating factor [to implement CancelRx] with the ultimate goals of improving communication and ensuring medication safety.”- Dr. Samantha Pitts

Implementing CancelRX led to immediate improvement and increased information exchange

The CancelRx implementation showed an immediate decrease in prescriptions that were dispensed after discontinuation in the EHR, from 8 percent to 1.4 percent. Dr. Pitts' team found that pharmacy staff sought additional information on the medication discontinuation, including clinical rationale for changes, and new medication guidance for patients. Dr. Pitts is encouraged that this tool has significant impact in reducing medication discrepancies and enhancing patient safety, and that CancelRX can potentially capture the needs of pharmacists and providers to ensure patient medication information is accurate. Adoption of CancelRx and expanding its functionality to include medications from outside the EHR could further reduce the risk of medication errors.