Medication Safety Issues Research Articles

2018 ACC/HRS/NASCI/SCAI/SCCT Expert Consensus Document on Optimal Use of Ionizing Radiation in Cardiovascular Imaging: Best Practices for Safety and Effectiveness.

2018 ACC/HRS/NASCI/SCAI/SCCT Expert Consensus Document on Optimal Use of Ionizing Radiation in Cardiovascular Imaging: Best Practices for Safety and Effectiveness.

Implementing a Comprehensive Unit-Based Safety Program (CUSP) to Enhance a Culture of Patient Safety and Improve Medication Safety in a Regional Home Care Program.

To determine whether a Comprehensive Unit-based Safety Program could be used to enhance a culture of patient safety and improve medication safety at 1 pilot site. The Canadian Patient Safety Culture Survey tool was used to assess the culture of patient safety and drill down on the key factors contributing to medication errors. Based on staff input and site improvement team investigations, solutions were developed to address medication safety issues. The main outcome measure was pre-/postintervention Canadian Patient Safety Culture scores. Change in frequency of occurrence reporting and staff's overall project experience were also measured. Overall perceptions of patient safety culture improved from 70% preintervention to 76.8% postintervention, representing a 9.7% change. Volume of occurrence reporting showed a marked increase postintervention. The project was well received by staff, with 84% rating their experience as "Good" to "Excellent." Finally 100% of participants reported that they learned something new and that this information could be applied to improve their day-to-day work. Implementing a Comprehensive Unit-based Safety Program improved staff's perceptions of patient safety, contributing to improved medication safety. To our knowledge, this is the first application of Comprehensive Unit-based Safety Program to successfully enhance patient safety in the home care setting.

It’s Like Scanning the Spoon: Problems and Interventions in Insulin Pen Safety

This paper describes a multifaceted patient safety project undertaken to address the complex medication safety issues of single-patient insulin pens in the hospital setting. The project makes the following contributions: a) provides observation- and data-based insight into root causes for the wrong pen/wrong patient problem; b) provides multiple solutions that can work together to significantly reduce the incidence of insulin pen-related safety events; c) shows how Quality and Safety methodologies can work hand-in-hand with human factors and human computer interaction methodologies to produce richer, more in depth results, and d) confirm expert recommendations for best practices that can reduce risks.

Pharmacist interventions in high-risk obstetric inpatient unit: a medication safety issue.

The aim of this study was to report number, type and severity of prescribing errors and pharmacist interventions in high-risk pregnant and postpartum women. A prospective cross-sectional, observational study. A high-risk obstetric inpatient unit of a Women's Hospital in Brazil. About 1826 electronic prescriptions for 549 women in the high-risk obstetrics inpatient unit were included. When the pharmacist detected potential prescribing errors, interventions were suggested. Prescriptions were evaluated by clinical pharmacist to identify the type, frequency and severity of prescribing errors and rate of clinical pharmacist intervention acceptance in a high-risk obstetric inpatient. A total of 1826 prescriptions were reviewed with 128 errors (7.0%). The most frequent errors were drug interaction (43.8%), incorrect frequency (21.5%) and improper dose (13.1%). One-hundred and sixty-eight interventions were made by pharmacists, 98.8% of which were accepted by prescribers. Higher maternal age (OR 1.0 (95%CI 1.0-1.1)), higher number of prescribed medications (OR 1.2 (95%CI 1.1-1.3)), obstetric conditions (OR 2.2 (95%CI 1.4-3.3)) and non-breastfeeding postpartum women (OR 3.9 (95% CI 2.5-6.1)) were the independent factors associated with prescribing errors identified through multivariate analysis. The most common prescription errors related to drug interactions, incorrect frequency and higher number of prescribed medications. The rate of pharmacist acceptance intervention was high.

Improving Transplant Medication Safety Through a Pharmacist-Empowered, Patient-Centered, mHealth-Based Intervention: TRANSAFE Rx Study Protocol.

BackgroundMedication errors, adverse drug events, and nonadherence are the predominant causes of graft loss in kidney transplant recipients and lead to increased healthcare utilization. Research has demonstrated that clinical pharmacists have the unique education and training to identify these events early and develop strategies to mitigate or prevent downstream sequelae. In addition, studies utilizing mHealth interventions have demonstrated success in improving the control of chronic conditions that lead to kidney transplant deterioration.ObjectiveThe goal of the prospective, randomized TRANSAFE Rx study is to measure the clinical and economic effectiveness of a pharmacist-led, mHealth-based intervention, as compared to usual care, in kidney transplant recipients.MethodsTRANSAFE Rx is a 12-month, parallel, two-arm, 1:1 randomized controlled clinical trial involving 136 participants (68 in each arm) and measuring the clinical and economic effectiveness of a pharmacist-led intervention which utilizes an innovative mobile health application to improve medication safety and health outcomes, as compared to usual posttransplant care.ResultsThe primary outcome measure of this study will be the incidence and severity of MEs and ADRs, which will be identified, categorized, and compared between the intervention and control cohorts. The exploratory outcome measures of this study are to compare the incidence and severity of acute rejections, infections, graft function, graft loss, and death between research cohorts and measure the association between medication safety issues and these events. Additional data that will be gathered includes sociodemographics, health literacy, depression, and support.ConclusionsWith this report we describe the study design, methods, and outcome measures that will be utilized in the ongoing TRANSAFE Rx clinical trial.Trial RegistrationClinicalTrials.gov NCT03247322: https://clinicaltrials.gov/ct2/show/NCT03247322 (Archived by WebCite at http://www.webcitation.org/6xcSUnuzW)

The Prescription Drug User Fee Act: Cause for Concern?

The Prescription Drug User Fee Act (PDUFA) was originally enacted into law in 1992. PDUFA provides the Food and Drug Administration (FDA) with needed revenue in the form of various fees paid by drug and biologic manufacturers. The FDA utilizes this revenue to streamline the review and approval process for medications. Since the enactment of PDUFA, the median approval time for priority new drug applications and biologics license applications has reduced significantly. The FDA views PDUFA as a successful program that provides a consistent revenue stream to the agency, improves access to medications for patients, and allows industry to have a more predictable product review timeline. However, critics of PDUFA cite concerns including the potential for a lack of FDA independence and medication safety issues involving drugs approved after the existence of PDUFA.

Barriers to the medication error reporting process within the Irish National Ambulance Service, a focus group study.

Incident reporting is vital to identifying pre-hospital medication safety issues because literature suggests that the majority of errors pre-hospital are self-identified. In 2016, the National Ambulance Service (NAS) reported 11 medication errors to the national body with responsibility for risk management and insurance cover. The Health Information and Quality Authority in 2014 stated that reporting of clinical incidents, of which medication errors are a subset, was not felt to be representative of the actual events occurring. Even though reporting systems are in place, the levels appear to be well below what might be expected. Little data is available to explain this apparent discrepancy. To identify, investigate and document the barriers to medication error reporting within the NAS. An independent moderator led four focus groups in March of 2016. A convenience sample of 18 frontline Paramedics and Advanced Paramedics from Cork City and County discussed medication errors and the medication error reporting process. The sessions were recorded and anonymised, and the data was analysed using a process of thematic analysis. Practitioners understood the value of reporting errors. Barriers to reporting included fear of consequences and ridicule, procedural ambiguity, lack of feedback and a perceived lack of both consistency and confidentiality. The perceived consequences for making an error included professional, financial, litigious and psychological. Staff appeared willing to admit errors in a psychologically safe environment. Barriers to reporting are in line with international evidence. Time constraints prevented achievement of thematic saturation. Further study is warranted.

Contemporary utilization of antithrombotic therapy for stroke prevention in patients with atrial fibrillation: an audit in an Australian hospital setting.

To document antithrombotic utilization in patients with nonvalvular atrial fibrillation (NVAF), particularly, recently approved NOACs (nonvitamin K antagonist oral anticoagulants) and warfarin; and identify factors predicting the use of NOACs versus warfarin. A retrospective audit was conducted in an Australian hospital. Data pertaining to inpatients diagnosed with atrial fibrillation (AF) admitted between January and December 2014 were extracted. This included patient demographics, risk factors (stroke, bleeding), social history, medical conditions, medication history, medication safety issues, medication adherence, and antithrombotic prescribed at admission and discharge. Among 199 patients reviewed, 84.0% were discharged on antithrombotics. Anticoagulants (± antiplatelets) were most frequently (52.0%) prescribed (two-thirds were prescribed warfarin, the remainder NOACs), followed by antiplatelets (33.0%). Among 41 patients receiving NOACs, 59.0% were prescribed rivaroxaban, 24.0% dabigatran, and 17.0% apixaban. Among patients aged 75 years and over, antiplatelets were most frequently used (37.0%), followed by warfarin (33.0%), then NOACs (14.0%). Compared with their younger counterparts, patients aged 75 years and over were significantly less likely to receive NOACs (14.0% versus 28.0%, p = 0.01). Among the 'most eligible' patients (Congestive Cardiac Failure, Hypertension (, Age ⩾ 75 years, Age= 65-74 years, Diabetes Mellitus, Stroke/ Transient Ischaemic Attack/ Thromboembolism, Vascular disease, Sex female[CHA2DS2-VASc] score ⩾2 and no bleeding risk factors), 46.0% were not anticoagulated on discharge. Patients with anaemia (68.0% versus 86.0%, p = 0.04) or a history of bleeding (65.0% versus 87.0%, p = 0.01) were less likely to receive antithrombotics compared with those without these risk factors. Warfarin therapy was less frequently prescribed among patients with cognitive impairment compared with patients with no cognitive issues (12.0% versus 23.0%, p = 0.01). Multivariate logistic regression modelling identified that patients with renal impairment were 3.6 times more likely to receive warfarin compared with NOACs (odds ratio = 3.6, 95% confidence interval = 0.08-0.90, p = 0.03, 60.0% correctly predicted; Cox and Snell R2 = 0.51, Nagelkerke R2 = 0.69). Despite the availability of NOACs, warfarin remains a preferred treatment option, particularly among patients with renal impairment. The high proportion of eligible patients still being prescribed antiplatelet therapy or 'no therapy' needs to be addressed.

National Survey Of Medication Safety Practice At Ministry Of Health Hospitals During Mass Gathering (Hajj-2016) In Saudi Arabia

To explore the medication safety practice at Ministry of Health (MOH) hospitals during mass gathering (Hajj -2016) in Saudi Arabia It is a 15-days cross-sectional national survey of medication safety practice at Makkah hospitals during mass gathering Hajj period. The survey modified from Institution of Safe Medication Practice (ISMP) self-assessment of medication safety practice at hospitals. It consisted of a demographic section and ten domains with 270 questions. The ten areas included patient information, drug information, communication of medication orders, drug preparation, medication distribution, medication devices, work environment, staff competency, patient education, quality process with risk management domain. The 5-points Likert response scale system used. The survey distributed to sixteen directors of hospital pharmacy during mass gathering Hajj-2016. The medications safety officer at Makkah region distributed the questionnaire and made follow up on a daily basis used physical visiting and through the telephone call. The study made as an electronic format, and it analyzed through survey monkey system The survey distributed to sixteen hospitals, the response rate, was eleven hospitals (68.75%). Of those 4 (36.4%) hospitals bed size was (100-199) and 3 (27.3%) bed size (200-299). The responded 4(36.4%) hospitals were accredited by Saudi Central Board of Hospitals Accreditation (CBAHI) while 3 (27.3%) accredited by USA International Joint Commission and CIBAHI. The whole sections score of all hospital were (66.4 %). Of the ten domain the patient information was (57.2%), Drug Information (58%), communication of medication orders (70.5%), drug preparation (73.7%), medication distribution (70.22%), medication devices (59.3%), work environment (78.62%), staff competency (73.86%), patient education (74.9 %), and quality process with risk management (62.96 %). The potential medication safety practice was the lowest score, and it was patient information and drug information field. Targeting to correct all related medication safety issues prevent drug misadventures, improved patient clinical outcomes, and quality of life.

Understanding the impact of supervision on reducing medication risks: an interview study in long-term elderly care

BackgroundIn 2009, the Dutch Health Care Inspectorate (IGZ) observed several serious risks to safety involving medication within elderly care facilities. However, by 2011, high risks had been reduced in almost all the organisations we visited. And yet the IGZ analysed too the alarming increase in the number of incidents arising in the self-reported national indicator of medication safety between 2009 and 2010. The aim of this study was to understand the factors that can explain this contradiction between the increase in self-reported medication incidents and the observation of the IGZ in reducing the risks to medication safety through supervision.MethodsWe interviewed health care professionals of ten care facilities, visited by the IGZ, who were involved in, or responsible for, the improvement of medication safety in their institutions. As outcome measures we used the rate of medication safety risk per facility; the perceptions of the participant with regard to the reports of medication incidents; the level of medication safety of the facility; the measures used to improve medication safety; and the supervision of medication safety.This was a mixed methods study, qualitative in that we used semi-structured interviews, and quantitative, by calculating risks for the different organisations we visited. The findings from both study methods resulted in a comprehensive view and an in-depth understanding of this contradiction.ResultsThe contradiction between the increase in self-reported medication incidents and the observation of reduced risks was explained by three themes: activities designed to improve medication safety, the reporting of medication incidents, and, lastly, the impact of supervision. The focus of the IGZ on issues of medication safety stimulated most elderly care facilities to reduce medication risks. Also, a change in the culture of reporting incidents caused an increase in the number of reported incidents.ConclusionsSupervision contributed to an improvement in actions geared towards reducing the risks associated with the safety of medication. It also increased a willingness to report such incidents. The more incidents reported are therefore not necessarily a sign of an increase in the risks, but can also be considered as a sign of a safer culture.

Design of an online medication safety module for clinicians.

In Australia, there are very few online courses addressing medication safety issues. Educating clinicians about medication safety is paramount given the increased responsibility of clinicians in advanced practice roles including nurses at several key points throughout the medication process that encompass prescribing, dispensing, administering and monitoring medications. The model used for the course design is based on adult teaching principles. The modules incorporate several knowledge-based presentations along with interactive activities. An integrative pedagogical approach is used in designing the modules in the online course. The online education modules target clinicians who work in the community setting. Although the modules are intended to reinforce the principles of medication safety principles identified in the literature, there is a focus on professional responsibility and understanding the laws governing medication disposals and handling. The course used an integrative approach suitable for pharmacy programs. The design and development of a medication safety online course was described by using the Australian Commission on Safety and Quality in Health Care and the 2011 Curriculum developed by the Royal Australian College of General Practitioners frameworks. The course has gained accreditation by the Australian Royal College of General Practice as part of its continuing education development programs.

Pilot of a Computerised Antithrombotic Risk Assessment Tool Version 2 (CARATV2.0) for stroke prevention in atrial fibrillation.

The decision-making process for stroke prevention in atrial fibrillation (AF) requires a comprehensive assessment of risk vs. benefit and an appropriate selection of antithrombotic agents (e.g., warfarin, non-vitamin K antagonist oral anticoagulants [NOACs]). The aim of this pilot-test was to examine the impact of a customised decision support tool - the Computerised Antithrombotic Risk Assessment Tool (CARATV2.0) using antithrombotic therapy on a cohort of patients with AF. In this prospective interventional study, 251 patients with AF aged ≥ 65 years, admitted to a teaching hospital in Australia were recruited. CARATV2.0 generated treatment recommendations based on patient medical information. Recommendations were provided to prescribers for consideration. At baseline (admission), 30.3% of patients were prescribed warfarin, 26.7% an antiplatelet, 8.4% apixaban, 8.0% rivaroxaban, 3.6% dabigatran. CARATV2.0 recommended a change of therapy for 153 (61.0%) patients. Through recommendations of CARATV2.0, at discharge, 40.2% of patients were prescribed warfarin, 17.7% antiplatelet, 14.3% apixaban, 10.4% rivaroxaban, 5.6% dabigatran. Overall, the proportion of patients receiving an antithrombotic on discharge increased significantly from baseline (admission) (baseline 77.2% vs. 89.2%; p < 0.001). Prescribers moderately agreed with CARATV2.0's recommendations (kappa = 0.275, p < 0.001). Practical medication safety issues were cited as major reasons for not accepting a desire to continue therapy with CARATV2.0's recommendations. Factors predicting the prescription of antiplatelets rather than anticoagulants included higher bleeding risk and high risk of falls. An inter-speciality difference in therapy selection was detected. This decision support tool can help optimise the use of antithrombotic therapy in patients with AF by considering risk versus benefit profiles and rationalising treatment selection. (Cardiol J 2017; 24, 2: 176-187).

Management of neuroendocrine tumors.

Current strategies for managing neuroendocrine tumors (NETs) in adult patients are reviewed, with a focus on medication safety concerns. NETs usually originate in the gastrointestinal or bronchopulmonary tract. Symptoms due to hormonal hypersecretion often occur in patients with foregut or midgut NETs or liver metastases. Surgical resection is recommended for most localized NETs, while systemic cytotoxic chemotherapy is typically used for high-grade and pancreatic tumors. The standard of care for metastatic NETs is somatostatin analog therapy with octreotide (available in both short- and long-acting formulations) or a depot formulation of lanreotide. Everolimus and sunitinib are targeted therapies with approved indications for use in treating advanced pancreatic NETs. Some patients with liver-predominant disease or liver metastases may undergo regional chemoembolization procedures. Pharmacists should be cognizant of differences between newer and older chemoembolization agents and procedures, as well as differences between somatostatin analog products used as medications and the radiolabelled forms used in diagnostic scintigraphy. Other medication safety issues in NET management arise during perioperative supportive care, patient education, compliance counseling, and management of adverse effects of targeted therapies and chemotherapy, including stomatitis, hyperthyroidism, and hand-foot skin reaction. Somatostatin analog therapy is the mainstay for management of locally advanced or metastatic NETs. Liver-directed therapy is an option for localized unresectable disease; platinum-based chemotherapy is the first-line treatment for poorly differentiated tumors. Optimal sequencing of these treatments and targeted therapies such as everolimus and tyrosine kinase inhibitors remains to be elucidated.

Improving patient safety reporting with the common formats: Common data representation for Patient Safety Organizations

Medical errors and patient safety issues remain a significant problem for the healthcare industry in the United States. The Institute of Medicine report To Err is Human reported that there were as many as 98,000 deaths per year due to medical error as of 1999. Many authors and government officials believe that the first step on the path to improvement in patient safety is more comprehensive collection and analysis of patient safety events. The belief is that this will enable safety improvements based on data showing the nature and frequency of events that occur, and the effectiveness of interventions. This systematization of healthcare practice can be a step in the right direction toward a value based, safety conscious and effective healthcare system. To help standardize this reporting and analysis, AHRQ created Common Formats for Patient Safety data collection and reporting. This manuscript describes the development of patient safety reporting and learning through the Patient Safety Organizations (PSO)s and the Common Formats and gives readers an overview of how the system is expected to function and the breadth of development of the Common Formats to date.

Pictograms for Safer Medication Management by Health Care Workers.

Inherent risks are associated with the preparation and administration of medications. As such, a key aspect of medication safety is to ensure safe medication management practices. To identify key medication safety issues and high-alert drug classes that might benefit from implementation of pictograms, for use by health care providers, to enhance medication administration safety. This study was the first step in the development of such pictograms. Self-identified medication management experts participated in a modified Delphi process to achieve consensus on situations where safety pictograms are required for labelling to optimize safe medication management. The study was divided into 3 phases: issue generation, issue reduction, and issue selection. Issues achieving at least 80% consensus and deemed most essential were selected for future studies. Retained issues were subjected to semiotic analysis, and preliminary pictograms were developed. Of the 87 health care professionals (pharmacists, pharmacy technicians, nurses, and physicians) invited to participate in the Delphi process, 30 participated in all 3 phases. A total of 55 situations that could potentially benefit from safety pictograms were generated initially. Through the Delphi process, these were narrowed down to 10 situations where medication safety might be increased with the use of safety pictograms. For most of the retained issues, between 3 and 6 pictograms were designed, based on the results of the semiotic analysis. The pharmacists, pharmacy technicians, nurses, and physicians participating in this study reached consensus and identified 10 medication administration safety issues that might benefit from the development and implementation of safety pictograms. Pictograms were developed for a total of 9 issues. In follow-up studies, these pictograms will be validated for comprehension and evaluated for effectiveness.

Meaningful use and good catches: More appropriate metrics for checklist effectiveness

The benefit of utilizing surgical safety checklists has been recently questioned. We evaluated our checklist performance after implementing a program that includes checklist-related good catches. Multifaceted interventions aimed at the preincision checklist and 5 prospective audits were conducted from 2011-2015. We documented adherence to the checklist (verbalization of each checkpoint), fidelity (meaningful performance of each checkpoint), and good catches (events with the potential to cause the patient harm but that were prevented from occurring). Good catches were divided into quality improvement-based categories (processes, medication, safety, communication, and equipment). A total of 1,346 checklist performances were observed (range, 144-373/yr). Adherence to the preincision checklist improved from 30% to 95% (P<.001), while adherence to the preinduction and debriefing checklists decreased (71% to 56%, P=.002) and remained unchanged (76%), respectively. Preincision fidelity decreased from 86% to 76% (P=.012). Good catches were identified during 16% of preincision checklist performances; process issues were most common (32%) followed by issues of medication administration (30%) and safety (22%). Implementation of a systematic checklist program resulted in significant and sustainable improvement in performance. Meaningful use and associated good catches may be more appropriate metric than actual patient harm for measuring checklist effectiveness. Although not previously described, checklist-related good catches represent an unknown benefit of checklists.

Decision-making around antithrombotics for stroke prevention in atrial fibrillation: the health professionals' views.

Background For stroke prevention in patients with atrial fibrillation (AF), the decision-making around antithrombotic therapy has been complicated by older age, multiple comorbidities, polypharmacy and the different pharmacological properties of warfarin and the nonvitamin K antagonist oral anticoagulants (NOACs). The complexity of decision-making has been associated with a reluctance by health professionals to use antithrombotic therapy, leading to poor clinical outcomes. In order to improve stroke prevention in patients with AF, the contemporary perspectives of health professionals on the decision-making around antithrombotic therapy needs exploration. Objective To elicit emerging themes describing health professionals' perspectives on the decision-making around antithrombotic therapy for stroke prevention in patients with AF. Setting Sydney metropolitan area of New South Wales, Australia. Method A qualitative study based on face-to-face interviews was conducted from August to October 2014. Seven pharmacists, seven specialists, six general practitioners and six nurses practising in the Sydney metropolitan area and managing antithrombotic therapy for AF were interviewed until theme saturation was achieved in each subgroup. Interview transcripts were analysed using manual inductive coding. Main outcome measure Emerging themes describing health professionals' perspectives on the decision-making around antithrombotic therapy for stroke prevention in patients with AF. Results Three overarching themes emerged. (1) Comprehensive assessment is necessary for decision-making but is not always implemented. Health professionals mostly focused on stroke risk assessment, not on the bleeding risk and medication safety issues. (2) Health professionals from different disciplines have different preferences for antithrombotic therapies. Although the majority of health professionals considered warfarin as the first-line therapy, NOACs were preferred by neurologists and haematologists. (3) Health professionals focused on different aspects of the decision making process: GPs and specialists were concerned about the appropriate prescription of antithrombotics, while pharmacists and nurses focused on daily medication management by patients. Conclusion The decision-making process appears to be partially preference based rather than systematic, and health professionals from various disciplines focus on different parts of the decision-making process.

Medication Safety

Medication Safety

A retrospective study of in-hospital cardiac arrest.

In-hospital cardiac arrest is an important issue in health care today. Data regarding in-hospital cardiac arrest in Japan is limited. In Australia and the USA, the Rapid Response System has been implemented in many institutions and data regarding in-hospital cardiac arrest are collected to evaluate the efficacy of the Rapid Response System. This is a multicenter retrospective survey of in-hospital cardiac arrest, providing data before implementing a Rapid Response System. Ten institutions planning to introduce a Rapid Response System were recruited to collect in-hospital cardiac arrest data. The Institutional Review Board at each participating institution approved this study. Data for patients admitted at each institution from April 1, 2011 until March 31, 2012 were extracted using the three keywords "closed-chest compression", "epinephrine", and "defibrillation". Patients under 18 years old, or who suffered cardiac arrest in the emergency room or the intensive care unit were excluded. A total of 228 patients in 10 institutions were identified. The average age was 73 ± 13 years. Males represented 64% of the patients (82/146). Overall survival after in-hospital cardiac arrest was 7% (16/228). Possibly preventable cardiac arrests represented 15% (33/228) of patients, with medical safety issues identified in 8% (19/228). Vital sign abnormalities before cardiac arrest were observed in 63% (138/216) of patients. Approximately 60% of patients had abnormal vital signs before cardiac arrest. These patients may have an improved clinical outcome by implementing a Rapid Response System.

Free-Text Notes as a Marker of Needed Improvements in Electronic Prescribing.

In this issueof JAMAInternalMedicine,Dhavleandcolleagues1 presenttheresultsofastudyindicatingthat,of the14.9%ofelectronic prescriptions with free-text notes, 66.1% contained inappropriate content forwhicha structureddata field (ie, a field intended for certain specific piecesof information, suchas days’ supply or indication for a medication) exists in the mostcommonlyusednationale-prescribingstandard.Mostconcerning, almost 1 in5 (19.0%)of these inappropriatenotes contained conflicting medication directions from the structured fields intended for this purpose. Of the noteswith appropriate content, almost half (47.3%) contained information that could be communicated using structured fields approved in a version of the e-prescribing standard that has yet to be implemented. An additional 9.6% were prescription cancellation requests for which a separate e-prescribing message exists but is not widely supported in most currently available e-prescribing software. The implications of these various types of free-text notes can range from the merely distracting for the community pharmacist to those that could be severely harmful for patients (Table). However, even distractions can lead indirectly to patient harm if they result in lapses of attention that increase the rate of dispensing errors. Several of these categories of notes are time consuming for pharmacists and sometimes for prescribers (eg, if telephone calls are needed to clarify a prescription), therefore wasting valuable health care resources. Moreover, the final category in this Table (ie, conflicting information), as illustrated in the phenytoin sodium (Dilantin) example in the Discussion section by Dhavle and colleagues1 (and included in the present Table) is not infrequent: conflicting informationapparentlyoccurred in 14.6% of all prescriptionswith free-text codes sampled byDhavle et al, or approximately 2.2% of all e-prescriptions. If extrapolated nationally, assuming SureScripts captures two-thirds of all new e-prescriptions in the United States, this wouldmean that more than 34 million such errors occur each year. As with most medication safety issues, the causes of the problemaremultifactorial. Failure of prescribers to use available structured fields likely reflects a combination of poor usabilityof electronichealth records ande-prescribing toolsplus a lack of adequate education, training, and feedback among prescribers. Indeed, in common practice, few such educationalopportunities exist: prescribersoftenhavea single training sessionwhen a new system is implemented or when they join a new practice and have no opportunities for feedback, especially frompharmacists. Failure of approved standards to bewidely implemented reflects deficiencies in regulation and in the health information technology development process. The types of information in these free-text notes also reveals awide communication gulf betweenprescribers andpharmacies, agulf that canonlybepartiallybridgedwithcurrent tools, technologies, and health care structures. Because the causes of this problemaremultifactorial, the solutions must be as well. Vendors of electronic health records and e-prescribing software should view the findings of Dhavle and colleagues1as a guide to improvements thatmust bemade in theusability of their products. For example,many vendorsoftenmake itdifficult toefficientlyandaccuratelyprescribe sliding scales, tapers, or other complicated regimens (eg, “take 1 capsule in themorning and 2 capsules in the evening,” which was likely the intention of the prescriber of the above-mentioned phenytoin example). Updates in currently approvede-prescribing standards shouldbeexpeditedand integrated into thenextgenerationof tools; suchchanges should receive the highest priority by regulators and vendors. Future updates to the standards will also need to be developed and expedited. New structured fields should be considered when there is risk for this type of information to be omitted or incomplete when not prompted. Prescribers need adequate training in theuseof e-prescribing tools.Moreover, onRelated article page 463