Enhancing medication safety with System Approach to Verifying Electronic Prescriptions (SAV E-Rx): pharmacists' review of product selection outcomes between prescribed and dispensed medications.
Jun Gong, Vincent D Marshall, Megan Whitaker, Brigid Rowell, Michael P Dorsch, James P Bagian, Corey A Lester
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Abstract
Objectives: Electronic prescriptions (e-prescriptions) introduce drug product selection mismatches during pharmacy data entry. System Approach to Verifying Electronic Prescriptions (SAV E-Rx) detects and alerts pharmacy staff to clinically significant occurrences. This study evaluates outcomes of the identified mismatches.
Methods: A retrospective analysis was conducted using 1 year of e-prescriptions and dispensing data from 14 community pharmacies across 9 US states. SAV E-Rx screened the data, and flagged mismatches were reviewed by pharmacists using the Common Formats for Event Reporting. Data were analysed using descriptive statistics, the Mann-Whitney U test and χ2 tests.
Results: Of 1 250 804 records processed, 699 662 included sufficient data for comparison. Pharmacists classified 587 (88.7%) flagged records as intended mismatches and 75 (11.3%) as unintended. Intended mismatches involved ingredients (26.2%), strengths (53.7%) and dosage forms (47.4%), mainly due to prescriber-approved substitutions (62.4%). Unintended mismatches stemmed from ingredients (42.7%), strengths (36.0%) and dosage forms (54.7%) discrepancies, primarily reported as human error (82.7%) and labelling issues (76.0%). Future alerts were favoured for unintended mismatches (96.0%) compared with intended mismatches (56.7%) (p<0.001).
Discussion: While routine substitutions are a normal part of quality and timely care, unintended mismatches may pose clinical risks. These errors can arise from human factors and workflow challenges, including high prescription volumes and manual overrides. SAV E-Rx serves as an independent, automated safety net that flags mismatches, catching postdispensing errors that would otherwise go unnoticed.
Conclusions: E-prescription errors remain a safety concern. Routine implementation of SAV E-Rx could enhance error detection and enable timely interventions.
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