Error Alert
Institute for Safe Medication Practices, Horsham, PA
When a patient recently visited a hospital clinic, a practitioner was reconciling external medication information available in the patient’s electronic health record (EHR) via medication history data from Surescripts. Based on Surescripts information, the patient was taking oral enalapril 5 mg daily. When the patient was asked if she was still taking this medication, she reported that the enalapril was for her dog. The clinic staff called the patient’s community pharmacy, which confirmed that the enalapril was indeed for the patient’s dog.
Risk factors for error
It is uncertain how Surescripts captured the prescription for enalapril as the owner’s medication and presented it in Epic for reconciliation. The community pharmacist noted that it is company policy to use both the pet owner’s last name and date of birth when creating a pharmacy profile for a pet. Given similarities between the owner and pet profiles (i.e., last name, birthdate, address, telephone number), perhaps the pharmacist erroneously selected the owner’s profile at some point when entering the enalapril prescription.
Fortunately, the patient was able to confirm that the medication was for her dog. However, if the patient had been admitted to a facility and was not able to help during the reconciliation process (e.g., unaware of medication names, confused), the risk of an error would be high. The pet’s medication could have been added to the patient’s list of “home medications” and prescribed during hospitalization, and even upon discharge. This is particularly a concern with medications such as insulin, anticonvulsants, antidepressants, anxiolytics, and analgesics, which are commonly prescribed for pets and often filled in community pharmacies.
Follow-up with several community pharmacies indicated that no formal policy exists on this subject, and that practices vary. Creating a profile for a pet using the pet owner’s last name, address, and telephone number is common. Some pharmacies have a separate field for the pet owner’s name in the pet profile. One pharmacy reported a checkbox in the profile to indicate that the patient was a pet. Another pharmacy said staff often add “canine” or “feline” to the name field. However, all the community pharmacies we contacted noted that they do not use the owner’s date of birth for the pet. Instead, they use the pet’s actual birthdate or a fictitious birthdate (e.g., 01/01/01, or January 1 with an educated guess for the year) if the pet’s actual birthdate is unknown. When pet owners pick up medications for their pets, verification of identity is usually by name and address, although some pharmacies require entry of the (fictitious) birthdate as a standard check.
Safe practice recommendations
Community pharmacies should implement a standardized policy and procedure that describes exactly how to create a unique pet profile in the pharmacy computer system. When designing the pet profile, make it look as different as possible from the owner’s profile (e.g., different color background, different fields, paws icon, pet pictogram). Document the animal’s species (e.g., as a part of the animal’s name). As allowed by state regulation, use the pet’s actual birthday, not the owner’s, for the pet’s profile. If unknown, use a standard process to determine a fictitious birthdate. When dispensing prescriptions, verification that the correct patient profile has been selected should include both the first and last name, along with the birthdate. All pharmacy staff should be educated about the policy and procedure.
In physician practices, clinics, and other health care facilities, be sure to confirm all the active medications presented in the EHR from both internal and external (e.g., Surescripts) sources with the patient, family member, and/or the patient’s local pharmacy at the start of every patient encounter.