Discharge order verification process to reduce prescription errors and optimize diabetes management.

Abstract

Background: Prescription errors at discharge have a detrimental impact on patients, especially in high-risk populations like those with diabetes mellitus (DM). A team-based, patient-centered approach has been shown to reduce medication errors and improve patient outcomes. To address this, an inpatient pharmacist-driven initiative was implemented, focusing on a discharge order verification process to review and intervene on antidiabetic prescriptions before they are e-prescribed.

Objective: The objective was to evaluate the effectiveness of a discharge order verification process in improving the prescribing of antidiabetic medications and supplies for DM patients before e-prescriptions are transmitted to community pharmacies.

Methods: This proof of concept study ran over 4-weeks and included adult patients with a diagnosis of DM and who had at least one discharge order for the management of DM. Orders populated into a discharge verification queue built into the electronic health record (EHR) system. When an order was received, an investigator pharmacist reviewed the chart to determine appropriateness, evaluating medication safety, effectiveness, and accessibility. Interventions to address drug-related problems were made in real-time. Once verified, e-prescriptions were transmitted to community pharmacies. Pharmacist interventions were quantified and categorized. Data was collected on the intervention type, proportion of patients discharged on an optimized regimen, length of time an order remained in the queue, interventions unlikely to be detected without EHR access, and intervention acceptance and execution.

Results: Overall,152 orders were verified on 63 patients. Thirty-eight patients (60.3%) had at least one order requiring intervention, totaling 56 interventions made overall. The most common interventions were additional drug necessary (17.9%), counseling required (16.1%), incorrect instructions (16.1%), and dosing adjustment (14.3%). Twenty-eight patients (73.7%) left on a newly optimized medication regimen.

Conclusion: This service model introduced a discharge order verification process for pharmacists to review and intervene on antidiabetic prescriptions before transmission to a community pharmacy. Pharmacist interventions effectively corrected errors, with a high rate of provider acceptance and execution of recommendations.