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Whitaker Mhi M, Lester C, Rowell B. Handing Off Electronic Prescription Data From Prescribers to Community Pharmacies: A Qualitative Analysis of Pharmacy Staff Perspectives. J Patient Saf 2024:01209203-990000000-00221. [PMID: 38742931 DOI: 10.1097/pts.0000000000001244] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/16/2024]
Abstract
OBJECTIVES The aims of the study are to understand the process of how community pharmacies handle electronic prescriptions (e-prescriptions) and learn about different errors or potential errors encountered. METHODS Fifteen remote, semistructured interviews were conducted with community pharmacy staff. Interview analysis was done with two adapted Systems Engineering Initiative for Patient Safety methods to understand the workflow and an affinity wall, which led to key words that were tallied to understand the frequency of different issues. RESULTS Data entry in community pharmacies is a process that varies based on the different software platforms receiving e-prescriptions. Data entry of a medication product is typically a human-reliant process matching an e-prescription with an equivalent medication product. Current automated safety supports focus on matching the dispensed medication to the medication chosen at data entry. Substitutions may be required for a variety of reasons, however, pharmacists' comfort and permissions in doing so without provider involvement fluctuates. CONCLUSIONS Prescription errors remain that could be prevented with additional support at the data entry step of e-prescriptions. Few studies demonstrate where these errors originate and what role current technology plays in contributing to or preventing these errors. Future work must consider how these matches between prescribed medications and pharmacy fulfilled medications occur. There is a need to identify potential tools to support data entry and prevent medication errors.
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Affiliation(s)
- Megan Whitaker Mhi
- From the School of Information & School of Public Health, University of Michigan, Ann Arbor, Michigan
| | - Corey Lester
- College of Pharmacy, University of Michigan, Ann Arbor, Michigan
| | - Brigid Rowell
- College of Pharmacy, University of Michigan, Ann Arbor, Michigan
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Creating a Stronger Culture of Safety Within US Community Pharmacies. Jt Comm J Qual Patient Saf 2023; 49:280-284. [PMID: 36907723 DOI: 10.1016/j.jcjq.2023.01.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2022] [Revised: 01/23/2023] [Accepted: 01/25/2023] [Indexed: 02/12/2023]
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Lester CA, Flynn AJ, Marshall VD, Rochowiak S, Bagian JP. Implementation outcomes of the Structured and Codified SIG format in electronic prescription directions. J Am Med Inform Assoc 2022; 29:1859-1869. [PMID: 35927972 PMCID: PMC9552209 DOI: 10.1093/jamia/ocac124] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2022] [Revised: 06/09/2022] [Accepted: 07/29/2022] [Indexed: 11/13/2022] Open
Abstract
OBJECTIVE To determine the extent of implementation, completeness, and accuracy of Structured and Codified SIG (S&C SIG) directions on electronic prescriptions (e-prescriptions). MATERIALS AND METHODS A retrospective analysis of a random sample of 3.8 million e-prescriptions sent from electronic prescribing (e-prescribing) software to outpatient pharmacies in the United States between 2019 and 2021. Natural language processing was used to identify direction components, including action verb, dose, frequency, route, duration, and indication from free-text directions and were compared to the S&C SIG format. Inductive qualitative analysis of S&C direction identified error types and frequencies for each component. RESULTS Implementation of the S&C SIG format in e-prescribing software resulted in 32.4% of e-prescriptions transmitted with these standardized directions. Directions using the S&C SIG format contained a greater percentage of each direction component compared to free-text directions, except for the indication component. Structured and codified directions contained quality issues in 10.3% of cases. DISCUSSION Expanding adoption of more diverse direction terminology for the S&C SIG formats can improve the coverage of directions using the S&C SIG format. Building out e-prescribing software interfaces to include more direction components can improve patient medication use and safety. Quality improvement efforts, such as improving the design of e-prescribing software and auditing for discrepancies, are needed to identify and eliminate implementation-related issues with direction information from the S&C SIG format so that e-prescription directions are always accurately represented. CONCLUSION Although directions using the S&C SIG format may result in more complete directions, greater adoption of the format and best practices for preventing its incorrect use are necessary.
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Affiliation(s)
- Corey A Lester
- Department of Clinical Pharmacy, College of Pharmacy, University of Michigan, Ann Arbor, Michigan, USA
| | - Allen J Flynn
- Department of Learning Health Sciences, Michigan Medicine, University of Michigan, Ann Arbor, Michigan, USA
| | - Vincent D Marshall
- Department of Clinical Pharmacy, College of Pharmacy, University of Michigan, Ann Arbor, Michigan, USA
| | | | - James P Bagian
- Department of Industrial and Operations Engineering - College of Engineering and Department of Anesthesiology - Michigan Medicine, University of Michigan, Ann Arbor, Michigan, USA
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Lester CA, Flynn AJ, Marshall VD, Rochowiak S, Rowell B, Bagian JP. Comparing the variability of ingredient, strength, and dose form information from electronic prescriptions with RxNorm drug product descriptions. J Am Med Inform Assoc 2022; 29:1471-1479. [PMID: 35773948 DOI: 10.1093/jamia/ocac096] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2021] [Revised: 04/18/2022] [Accepted: 06/20/2022] [Indexed: 11/12/2022] Open
Abstract
OBJECTIVE To determine the variability of ingredient, strength, and dose form information from drug product descriptions in real-world electronic prescription (e-prescription) data. MATERIALS AND METHODS A sample of 10 399 324 e-prescriptions from 2019 to 2021 were obtained. Drug product descriptions were analyzed with a named entity extraction model and National Drug Codes (NDCs) were used to get RxNorm Concept Unique Identifiers (RxCUI) via RxNorm. The number of drug product description variants for each RxCUI was determined. Variants identified were compared to RxNorm to determine the extent of matching terminology used. RESULTS A total of 353 002 unique pairs of drug product descriptions and NDCs were analyzed. The median (1st-3rd quartile) number of variants extracted for each standardized expression in RxNorm, was 3 (2-7) for ingredients, 4 (2-8) for strength, and 41 (11-122) for dosage forms. Of the pairs, 42.35% of ingredients (n = 328 032), 51.23% of strengths (n = 321 706), and 10.60% of dose forms (n = 326 653) used matching terminology, while 16.31%, 24.85%, and 13.05% contained nonmatching terminology, respectively. DISCUSSION A wide variety of drug product descriptions makes it difficult to determine whether 2 drug product descriptions describe the same drug product (eg, using abbreviations to describe an active ingredient or using different units to represent a concentration). This results in patient safety risks that lead to incorrect drug products being ordered, dispensed, and used by patients. Implementation and use of standardized terminology may reduce these risks. CONCLUSION Drug product descriptions on real-world e-prescriptions exhibit large variation resulting in unnecessary ambiguity and potential patient safety risks.
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Affiliation(s)
- Corey A Lester
- Department of Clinical Pharmacy, College of Pharmacy, University of Michigan, Ann Arbor, Michigan, USA
| | - Allen J Flynn
- Department of Learning Health Sciences, Michigan Medicine, University of Michigan, Ann Arbor, Michigan, USA
| | - Vincent D Marshall
- Department of Clinical Pharmacy, College of Pharmacy, University of Michigan, Ann Arbor, Michigan, USA
| | | | - Brigid Rowell
- Department of Clinical Pharmacy, College of Pharmacy, University of Michigan, Ann Arbor, Michigan, USA
| | - James P Bagian
- Center for Risk Analysis Informed Decision Engineering, Department of Industrial and Operations Engineering, College of Engineering, University of Michigan, Ann Arbor, Michigan, USA
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Gullslett MK, Strand Bergmo T. Implementation of E-prescription for Multidose Dispensed Drugs: Qualitative Study of General Practitioners' Experiences. JMIR Hum Factors 2022; 9:e27431. [PMID: 35037881 PMCID: PMC8804951 DOI: 10.2196/27431] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2021] [Revised: 05/21/2021] [Accepted: 11/27/2021] [Indexed: 11/23/2022] Open
Abstract
Background Increased use of pharmaceuticals challenges both capacity and safety related to medication management for patients and changes in how general practitioners (GPs) and other health personnel interact with and follow up with patients. E-prescribing of multidose drug dispensing (eMDD) is 1 of the national measures being tested in Norway. Objective The objective of this study is to explore GPs’ experiences with the challenges and benefits of implementing eMDD in Norway. Methods Qualitative in-depth and group interviews were conducted with a total of 25 GPs between 2018 and 2020. Transcribed files were saved in NVivo to conduct a step-by-step content analysis. NVivo is a software tool for organizing, managing, and analyzing qualitative data. Results The study revealed that eMDD offers many benefits. At the same time, there are several challenges related to information, training, and initiation, as well as to the responsibility for the medication, interactions, and the risk of incorrect medication. An important activity in the start-up phase was an information meeting with pharmacies and technology suppliers, as well as exchanging information and instructions with pharmacies on how to get started. Four analytic themes emerged through the extraction of data: (1) start-up with eMDD (“Be patient”); (2) the need for training; (3) interaction, safety, and efficiency; and (4) the working day with eMDD. Conclusions There is a variation in different GPs’ needs regarding training and information, and considerable variation in competence and motivation related to the use of digital tools. There are also different degrees of understanding the everyday work of the other actors in the medication chain. In particular, the harmonization of medication lists related to the use of time, expenditures, and challenges with technological solutions in the introduction phase was emphasized as a challenge. Overall, GPs who have started using the system report great benefits; these are largely related to an increased overview of patients’ total medication lists, less time spent on prescribing prescriptions, and increased collaboration with pharmacies and nurses, both in service from providers in homes and in nursing homes.
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Affiliation(s)
| | - Trine Strand Bergmo
- Norwegian Centre for E-Health Research, University Hospital of North Norway, Tromsø, Norway
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Hilty DM, Armstrong CM, Smout SA, Crawford A, Maheu MM, Drude KP, Chan S, Yellowlees PM, Krupinski EA. PROVIDER TECHNOLOGY, FATIGUE AND WELL-BEING: A SCOPING REVIEW (Preprint). J Med Internet Res 2021; 24:e34451. [PMID: 35612880 PMCID: PMC9178447 DOI: 10.2196/34451] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2021] [Revised: 02/20/2022] [Accepted: 04/18/2022] [Indexed: 11/13/2022] Open
Abstract
Background Video and other technologies are reshaping the delivery of health care, yet barriers related to workflow and possible provider fatigue suggest that a thorough evaluation is needed for quality and process improvement. Objective This scoping review explored the relationship among technology, fatigue, and health care to improve the conditions for providers. Methods A 6-stage scoping review of literature (from 10 databases) published from 2000 to 2020 that focused on technology, health care, and fatigue was conducted. Technologies included synchronous video, telephone, informatics systems, asynchronous wearable sensors, and mobile health devices for health care in 4 concept areas related to provider experience: behavioral, cognitive, emotional, and physical impact; workplace at the individual, clinic, hospital, and system or organizational levels; well-being, burnout, and stress; and perceptions regarding technology. Qualitative content, discourse, and framework analyses were used to thematically analyze data for developing a spectrum of health to risk of fatigue to manifestations of burnout. Results Of the 4221 potential literature references, 202 (4.79%) were duplicates, and our review of the titles and abstracts of 4019 (95.21%) found that 3837 (90.9%) were irrelevant. A full-text review of 182 studies revealed that 12 (6.6%) studies met all the criteria related to technology, health care, and fatigue, and these studied the behavioral, emotional, cognitive, and physical impact of workflow at the individual, hospital, and system or organizational levels. Video and electronic health record use has been associated with physical eye fatigue; neck pain; stress; tiredness; and behavioral impacts related to additional effort owing to barriers, trouble with engagement, emotional wear and tear and exhaustion, cognitive inattention, effort, expecting problems, multitasking and workload, and emotional experiences (eg, anger, irritability, stress, and concern about well-being). An additional 14 studies that evaluated behavioral, emotional, and cognitive impacts without focusing on fatigue found high user ratings on data quality, accuracy, and processing but low satisfaction with clerical tasks, the effort required in work, and interruptions costing time, resulting in more errors, stress, and frustration. Our qualitative analysis suggests a spectrum from health to risk and provides an outline of organizational approaches to human factors and technology in health care. Business, occupational health, human factors, and well-being literature have not studied technology fatigue and burnout; however, their findings help contextualize technology-based fatigue to suggest guidelines. Few studies were found to contextually evaluate differences according to health professions and practice contexts. Conclusions Health care systems need to evaluate the impact of technology in accordance with the Quadruple Aim to support providers’ well-being and prevent workload burden, fatigue, and burnout. Implementation and effectiveness approaches and a multilevel approach with objective measures for clinical, human factors, training, professional development, and administrative workflow are suggested. This requires institutional strategies and competencies to integrate health care quality, technology and well-being outcomes.
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Affiliation(s)
- Donald M Hilty
- Department of Psychiatry & Behavioral Sciences, University of California Davis School of Medicine, Sacramento, CA, United States
- Northern California Veterans Affairs Health Care System, Mather, CA, United States
| | - Christina M Armstrong
- Office of Connected Care, Department of Veterans Affairs, Washington, DC, United States
| | - Shelby A Smout
- Virginia Commonwealth University, Richmond, VA, United States
| | - Allison Crawford
- Extension for Community Healthcare Outcomes, Ontario Mental Health at Centre for Addiction and Mental Health, University of Toronto Virtual Mental Health, and Canada Suicide Prevention Service, Toronto, ON, Canada
| | - Marlene M Maheu
- Telebehavioral Health Institute, LLC and Coalition for Technology in Behavioral Science, San Diego, CA, United States
| | - Kenneth P Drude
- Coalition for Technology in Behavioral Science & Ohio Board of Psychology, Dayton, OH, United States
| | - Steven Chan
- Department of Psychiatry & Behavioral Sciences, Stanford University School of Medicine & Veterans Affairs Palo Alto Health Care System, Palo Alto, CA, United States
| | - Peter M Yellowlees
- Department of Psychiatry & Behavioral Sciences, University of California Davis School of Medicine, Sacramento, CA, United States
| | - Elizabeth A Krupinski
- Department of Radiology & Imaging Sciences, Emory University School of Medicine, Atlanta, GA, United States
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Kassem AB, Saeed H, El Bassiouny NA, Kamal M. Assessment and analysis of outpatient medication errors related to pediatric prescriptions. Saudi Pharm J 2021; 29:1090-1095. [PMID: 34703362 PMCID: PMC8523327 DOI: 10.1016/j.jsps.2021.08.009] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2021] [Accepted: 08/01/2021] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND Medication errors are the errors that impact the efficacy and safety of the therapy. The impact of medication errors is higher for certain subjects, such as pediatrics, who require more attention. Hence, the current study aimed to investigate the types and frequency of outpatient medication errors of pediatric subjects related to different prescription types. METHODS A cross-sectional study was carried in several community pharmacies to record the medication errors found in outpatient pediatric prescriptions by gathering data from the outpatient prescriptions besides direct counseling with the subjects and their parents. Many medical resources (disease and drug-related) were used for checking the different aspects of medication errors. The data collection process included a preprepared sheet containing several items representing the medication errors in addition to a counseling session. Data were expressed as percentages and compared through the Chi-square test for results of handwritten and computerized prescriptions. RESULTS 752 outpatient pediatric prescriptions were recruited in the study as they involve medication errors. Among the highest percentage of medication errors was the absence of essential data in the prescription, such as diagnosis, age, and weight. The duration of the therapy and contraindication for some of the prescribed medications were among the highest recorded errors. Among the critical errors were the drug interaction and drug duplication that directly affect the drug's efficacy and safety. There was a significant difference between computerized and handwritten prescriptions regarding the number of medication errors related to each type. CONCLUSION Medication errors related to outpatient pediatric prescriptions vary from one to another prescription with predominant errors that influence the therapy's safety or efficacy. The role of patient counseling and prescription checking is critical for improving patient therapy.
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Affiliation(s)
- Amira B. Kassem
- Clinical Pharmacy and Pharmacy Practice Department, Faculty of Pharmacy, Damanhour University, Egypt
| | - Haitham Saeed
- Clinical Pharmacy Department, Faculty of Pharmacy, Beni-Suef University, Beni-Suef, Egypt
| | - Noha A. El Bassiouny
- Clinical Pharmacy and Pharmacy Practice Department, Faculty of Pharmacy, Damanhour University, Egypt
| | - Marwa Kamal
- Clinical Pharmacy Department, Faculty of Pharmacy, Fayoum University, Fayoum, Egypt
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Pereira NL, Avram R, So DY, Iturriaga E, Byrne J, Lennon RJ, Murthy V, Geller N, Goodman SG, Rihal C, Rosenberg Y, Bailey K, Pletcher MJ, Marcus GM, Farkouh ME, Olgin JE. Rationale and design of the TAILOR-PCI digital study: Transitioning a randomized controlled trial to a digital registry. Am Heart J 2021; 232:84-93. [PMID: 33129990 PMCID: PMC7833248 DOI: 10.1016/j.ahj.2020.10.069] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/08/2020] [Accepted: 10/24/2020] [Indexed: 01/23/2023]
Abstract
BACKGROUND Tailored Antiplatelet Initiation to Lessen Outcomes Due to Decreased Clopidogrel Response after Percutaneous Coronary Intervention (TAILOR-PCI) is the largest cardiovascular genotype-based randomized pragmatic trial (NCT#01742117) to evaluate the role of genotype-guided selection of oral P2Y12 inhibitor therapy in improving ischemic outcomes after PCI. The trial has been extended from the original 12- to 24-month follow-up, using study coordinator-initiated telephone visits. TAILOR-PCI Digital Study tests the feasibility of extending the trial follow-up in a subset of patients for up to 24 months using state-of-the-art digital solutions. The rationale, design, and approach of extended digital study of patients recruited into a large, international, multi-center clinical trial has not been previously described. METHODS A total of 930 patients from U.S. and Canadian sites previously enrolled in the 5,302 patient TAILOR-PCI trial within 23 months of randomization are invited by mail to the Digital Study website (http://tailorpci.eurekaplatform.org) and by up to 2 recruiting telephone calls. Eureka, a direct-to-participant digital research platform, is used to consent and collect prospective data on patients for the digital study. Patients are asked to answer health-related surveys at fixed intervals using the Eureka mobile app and or desktop platform. The likelihood of patients enrolled in a randomized clinical trial transitioning to a registry using digital technology, the reasons for nonparticipation and engagement rates are evaluated. To capture hospitalizations, patients may optionally enable geofencing, a process that allows background location tracking and triggering of surveys if a hospital visit greater than 4 hours is detected. In addition, patients answer digital hospitalization surveys every month. Hospitalization data received from the Digital Study will be compared to data collected from study coordinator telephone visits during the same time frame. CONCLUSIONS The TAILOR-PCI Digital Study evaluates the feasibility of transitioning a large multicenter randomized clinical trial to a digital registry. The study could provide evidence for the ability of digital technology to follow clinical trial patients and to ascertain trial-related events thus also building the foundation for conducting digital clinical trials. Such a digital approach may be especially pertinent in the era of COVID-19.
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Affiliation(s)
- Naveen L Pereira
- Department of Cardiovascular Diseases, Mayo Clinic, Rochester, MN.
| | - Robert Avram
- University of California San Francisco, San Francisco, CA
| | - Derek Y So
- University of Ottawa Heart Institute, Ottawa, Canada
| | - Erin Iturriaga
- National Heart, Lung, and Blood Institute (NHLBI), National Institutes of Health (NIH), Bethesda, MD
| | - Julia Byrne
- Department of Cardiovascular Diseases, Mayo Clinic, Rochester, MN
| | - Ryan J Lennon
- Department of Cardiovascular Diseases, Mayo Clinic, Rochester, MN
| | | | - Nancy Geller
- National Heart, Lung, and Blood Institute (NHLBI), National Institutes of Health (NIH), Bethesda, MD
| | - Shaun G Goodman
- St. Michael's Hospital, University of Toronto, Toronto, and Canadian VIGOUR Centre, University of Alberta, Edmonton, Canada
| | - Charanjit Rihal
- Department of Cardiovascular Diseases, Mayo Clinic, Rochester, MN
| | - Yves Rosenberg
- National Heart, Lung, and Blood Institute (NHLBI), National Institutes of Health (NIH), Bethesda, MD
| | - Kent Bailey
- Department of Cardiovascular Diseases, Mayo Clinic, Rochester, MN
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Panich J, Larson N, Sojka L, Wallace Z, Lokken J. Assessing automated product selection success rates in transmissions between electronic prescribing and community pharmacy platforms. J Am Med Inform Assoc 2021; 28:113-118. [PMID: 33186450 DOI: 10.1093/jamia/ocaa259] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2020] [Revised: 09/04/2020] [Accepted: 09/30/2020] [Indexed: 11/13/2022] Open
Abstract
OBJECTIVE Wrong drug product errors occurring in community pharmacies often originate at the transcription stage. Electronic prescribing and automated product selection are strategies to reduce product selection errors. However, it is unclear how often automated product selection succeeds in outpatient pharmacy platforms. MATERIALS AND METHODS The intake of over 800 e-prescriptions was observed at baseline and after intervention to assess the rate of automated product selection success. A dispensing accuracy audit was performed at baseline and postintervention to determine whether enhanced automated product selection would result in greater accuracy; data for both analyses were compared by 2x2 Chi square tests. In addition, an anonymous survey was sent to a convenience sample of 60 area community pharmacy managers. RESULTS At baseline, 79.8% of 888 e-prescriptions achieved automated product selection. After the intervention period, 84.5% of 903 e-prescriptions achieved automated product selection (P = .008). Analysis of dispensing accuracy audits detected a slight but not statistically significant improvement in accuracy rate (99.3% versus 98.9%, P = .359). Fourteen surveys were returned, revealing that other community pharmacies experience similar automated product selection failure rates. DISCUSSION Our results suggest that manual product selection by pharmacy personnel is required for a higher than anticipated proportion of e-prescriptions received and filled by community pharmacies, which may pose risks to both medication safety and efficiency. CONCLUSION The question of how to increase automated product selection rates and enhance interoperability between prescriber and community pharmacy platforms warrants further investigation.
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Affiliation(s)
- Jennifer Panich
- Clinical Pharmacy Services, Marshfield Clinic Health System, Marshfield, Wisconsin, USA
| | - Natalee Larson
- Clinical Pharmacy Services, Marshfield Clinic Health System, Marshfield, Wisconsin, USA
| | - Luanne Sojka
- Clinical Pharmacy Services, Marshfield Clinic Health System, Marshfield, Wisconsin, USA
| | - Zach Wallace
- Clinical Pharmacy Services, Marshfield Clinic Health System, Marshfield, Wisconsin, USA
| | - James Lokken
- Clinical Pharmacy Services, Marshfield Clinic Health System, Marshfield, Wisconsin, USA.,School of Pharmacy, Concordia University Wisconsin, Mequon, Wisconsin, USA
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