Original Research

Failures in Receiving Electronically Prescribed Antibiotics Following Cardiovascular Electronic Device Implantation

Zohaib A. Shaikh, BSE1; Brandon S. Needelman, BS1; Melanie L. Gershman1; Daniel J. Kersten, BA1; Sam N. Schwarzwald, BS1; Daniel I. Meshoyrer, BS1; Brian R. Malone, RPh, MS2; Todd J. Cohen, MD, FACC, FHRS1,2
1Department of Medicine, NYU Winthrop Hospital, Mineola, New York; 
2Department of Pharmacy, NYU Winthrop Hospital, Mineola, New York

Zohaib A. Shaikh, BSE1; Brandon S. Needelman, BS1; Melanie L. Gershman1; Daniel J. Kersten, BA1; Sam N. Schwarzwald, BS1; Daniel I. Meshoyrer, BS1; Brian R. Malone, RPh, MS2; Todd J. Cohen, MD, FACC, FHRS1,2
1Department of Medicine, NYU Winthrop Hospital, Mineola, New York; 
2Department of Pharmacy, NYU Winthrop Hospital, Mineola, New York

Abstract

Purpose: The purpose of this study was to review issues in receiving electronic prescriptions by patients’ pharmacies following implantation of cardiac implantable electronic devices at NYU Winthrop Hospital’s Electrophysiology Laboratory, and determine the degree of failure in receiving antibiotics using the electronic prescription system and any associated adverse effects, namely post-procedural infection. Methods: All patients who underwent a device procedure between March 28, 2016 through June 30, 2016 were eligible for our telephone survey, which assessed difficulties in receiving electronically prescribed medications and/or any signs and symptoms of infection. Results: Of 101 respondents, four (4.0 percent) reported difficulties in obtaining their electronically prescribed antibiotics from the pharmacy. After their pharmacies noted that they had not received their electronic prescriptions, these patients referred to their discharge instructions, called their physicians to alert them of the issue, and were subsequently able to receive their medications. The likely causes of electronic prescription delivery failure were a glitch in the electronic prescription software, submission error by the hospital’s practitioners, or error on the side of the pharmacy. No infections could be attributed to electronic prescription delivery failure. Conclusion: Discharge instructions are important for informing patients on how to obtain their medications when pharmacies failed to receive their electronic prescriptions. 
 
Keywords: e-prescribing; cardiac implantable electronic devices; antibiotic prophylaxis; medication error; risks and benefits

INTRODUCTION

As of March 27, 2016, the New York State Department of Health mandated that prescriptions for both controlled and non-controlled substances be written electronically.1 Beginning the next day, all prescriptions for prophylactic antibiotics following a cardiovascular device implantation or explantation at the NYU Winthrop Hospital (NYUWH) Electrophysiology (EP) Laboratory were required to be generated and sent using the electronic prescription features of the hospital’s INVISION® electronic medical record software (Siemens Medical Solutions USA) or those of the affiliated medical practices’ Office Practicum® electronic medical record software (Connexin Software, Inc.). There were isolated reports from patients reflecting failure to receive antibiotics using the electronic prescription system. 
 
The purpose of this study was to systematically review all patients who were prescribed antibiotics following device implantation or explantation in the NYUWH EP Laboratory and determine the degree of failure to receive antibiotics using the mandated electronic prescription system and any adverse effects caused by said failure, such as post-procedural infection. 

METHODS

All patients who underwent a device implant or explant procedure in the NYUWH EP Laboratory between March 28, 2016 and June 30, 2016 were considered eligible for the study. All physicians were advised that there may be problems with the electronic prescription system and that there were complaints from some patients about not receiving their postoperative antibiotics. All EP doctors gave verbal approval to survey their patients in order to determine the scope of these problems. As no identifying patient information was used or maintained, this study was deemed exempt from review by the institutional review board at NYU Winthrop Hospital. Patients were contacted by the authors via telephone between the days of July 7, 2016 and July 20, 2016 to complete an oral survey devised by the authors to assess electronic prescribing reliability (Figure 1). Patients were asked between four and six questions to ascertain whether there were issues in obtaining the prescribed antibiotics from the patients’ pharmacies and, if so, what actions the patients took to resolve them. Patients were also asked if they observed any signs of a persistent infection, including fevers, chills, redness, swelling, and discharge from the wound. Information on the type of prescription each patient received was obtained from the INVISION electronic medical record software.

RESULTS

A total of 226 patients were considered eligible for the survey. Of those, 101 patients or patient healthcare proxies (44.7 percent) verbally agreed to participate in the survey. Of the 101 respondents, 97 (96.0 percent) did not encounter any issues in receiving their antibiotics from the pharmacy. Four of the 101 respondents (4.0 percent) reported difficulties in obtaining their antibiotics. All four patients explained that their pharmacies failed to receive a prescription for antibiotics from NYUWH. After discovering the issue, all four patients called either the EP lab or their EP physician to alert them of the issue. Three of the four respondents were able to have the issue resolved via their EP physician, while one respondent asked a primary care physician to send another prescription for antibiotics. 
 
None of the patients that encountered electronic prescription issues experienced any signs or symptoms that may be attributed to infection, despite the delay in receiving their antibiotics. Notably, four other patients reported transient symptoms or signs possibly attributable to infection following their device procedure. Each of those patients received their postoperative antibiotics without issue, and all four were seen in follow-up with no infections identified.

DISCUSSION

The vast majority of electrophysiology patients who underwent device-related procedures did not encounter any problems in receiving their post-procedural prophylactic antibiotic regimen through the electronic prescription system. There were, however, four patients (4.0 percent) who initially failed to receive their prescribed postoperative antibiotics. These prescription delivery failures could potentially be due to a glitch in the electronic prescribing software, submission error by the hospital’s practitioner, and/or an error on the end of the pharmacy. Three patients were noted in the electronic medical software to have been given a paper prescription. However, at this time, the electronic prescription mandate was in effect, and a paper prescription should not have been an option. Only one of these three patients indicated that their prescription was not present in the pharmacy, and the practitioner recognized a mistake in submitting the prescription. It is uncertain what led to the prescriptions of the other two patients to be present in the pharmacy, so the exact cause of the error is unknown. The three other patients who encountered a problem were all electronically prescribed their medications.
 
This study emphasizes the importance of discharge instructions. All of the patients that did not receive their prescription at the pharmacy were informed, as part of their discharge instructions, which medications they required. One patient contacted her primary care physician, who then sent another prescription to the pharmacy. The other three patients contacted their respective operating physicians, who then resubmitted the electronic prescriptions. After these prescriptions were sent again through the electronic system, all of the patients received their antibiotics and did not develop any signs of infection or subsequent complaints. In the one year following provider training and completion of this study, the electrophysiology laboratory’s director was only aware of one potential electronic prescription failure, which again was resolved by the patient following their discharge instructions.   
 
The potential for operator error in electronic prescription submission was brought to the attention of NYUWH’s Health Informatics team, and the practitioners were educated on the importance of ensuring that their electronic prescriptions are sent properly. The operators were also informed of this potential for error and the need to follow up with their patients on this issue.
 
Post-implantation device infection can be a serious concern. Lack of antibiotic prophylaxis has been found to be a significant risk factor for infection.2-3 Once a device is infected, the vast majority of patients require device explantation, including lead extraction.4 Lead extraction can result in various complications, including massive hemorrhage, hemothorax, and damage to the tricuspid valve.4 Patients also require a course of both intravenous and oral antibiotics for two to six weeks, resulting in lengthy hospital stays.4 In many cases, patients then need to undergo a re-implantation procedure, which carries a higher risk of infection.2 A meta-analysis of prospective studies from 1981 to 2012 revealed an average device-related infection rate of 1.6 percent.2 The rate of infection has recently increased significantly, from 1.5 percent in 2004 to 2.4 percent in 2008.5 There have also been substantial increases in hospital costs and mortality rates due to infection of cardiovascular implantable electronic devices, from $75,000 and 2.91 percent, respectively, in 1993 to $146,000 and 4.69 percent in 2008.5 

Benefits of Electronic Prescribing

As many healthcare providers adopt electronic prescribing systems, the reliability of the new systems compared to traditional paper-based prescribing has been examined extensively. Electronic prescribing can offer many benefits to its adopters, including reducing the rate of medication errors compared to handwritten prescriptions.6-8 The implementation of a computerized physician order entry system in the wards of two medical centers in the Netherlands resulted in a 17 percent incidence of medication error, a significant reduction from a pre-implementation incidence of 55 percent.9 Similarly, Franklin et al10 reported that the prescribing error rate dropped from 3.8 percent to 2.0 percent following the implementation of a closed-loop electronic prescribing and administration system in a London teaching hospital. While a study by Westbrook et al11 also found a significant reduction in error rates associated with the use of an electronic prescribing system, this was driven by a large reduction in unclear, illegal, and incomplete orders. A limited change in clinical error rates was found, such as prescribing the wrong drug or dose, but serious errors were reduced by 44 percent. The use of an electronic system effectively eliminates illegible handwriting as a source of error,6,12 eradicating a major reason for clarification calls from pharmacies to prescribers.13 Features such as clinical decision support can provide information and alerts regarding drug interactions and patient allergies, preventing providers from prescribing medications that may harm their patients.14 Consequently, these reductions in prescription errors can save time and costs in patient care, even though electronic prescriptions may take marginally longer to issue than their handwritten counterparts.15
 
Electronic prescribing can offer additional benefits beyond reduction of medication errors. The electronic platform could facilitate checking patients’ insurance coverage and tailor patients’ treatment regimens to accommodate their financial situations.16 There is also potential for features to track patient compliance and history. Future updates could bring the ability to alert physicians when their patients have not picked up essential medications or help physicians discern whether their patients are likely to abuse medications based on the time between refill requests.16 The benefits of electronic prescribing allow for increased efficiency for both prescribers and pharmacies that use it.17  

Risks and Concerns with Electronic Prescribing

Although electronic prescribing systems retain many advantages over traditional paper prescriptions, they are still prone to error. An investigation by Nanji et al18 found that 11.7 percent of computerized prescriptions contained errors, 35 percent of which were considered potential adverse drug events. However, the error rate also depends on the system examined, varying from 5.1 percent to 37.5 percent.13,18-19 A variety of medication errors have been observed involving electronic prescribing. Among the most common problems were incorrect or unclear patient directions, wrong drug quantity, wrong drug, wrong dose, wrong dosage formulation, and/or wrong duration of therapy.20-23 A new and common type of error associated with electronic prescribing includes inappropriate use of free-text entry fields such as “Notes” or “Comments”, entering information that should have instead been entered into a standard data entry field.24 These errors can potentially lead to conflicting or ambiguous information and may require clarification. Notably, anti-infective medications such as antibiotics are the most common class of drugs found with errors in electronic prescriptions, mostly involving dosing directions or drug quantity.22 
 
Errors in electronic prescribing may lead to significant consequences for the patients, pharmacies, and prescribers involved. One study found that 13 percent of errors identified were significant, serious, or severe to the patient, involving issues such as an inadequate dose, overdose, or incorrect duration of therapy.20 Omitted, inaccurate, and unclear electronic prescriptions could be dangerous to patients and lead to adverse outcomes including inadequate disease management and potentially worsening the progression of disease. Errors in quantity and/or drug formulation can also lead to increased cost for the patient.22 Even when prescription errors are caught in the pharmacy before reaching the patient, they can lead to the disruption of workflow. Often, when the pharmacy staff encounters a potential error, they contact prescribers to receive clarification, resulting in delays for both the pharmacy and the patient.25-27 In addition, errors can lead to increased cost and inaccurate billing for pharmacies.22 
 
Software issues with electronic prescribing have also been prevalent in the literature. Some prescribers have complained of slow processing speeds, system freezes, constant update requirements, frequent and unnecessary safety alerts, and issues with the medication list.28 Physicians have previously encountered occasional difficulties with electronic transmission and connectivity with pharmacies.28 Glitches in the electronic systems sometimes keep pharmacies from receiving an electronic prescription after submission,17 requiring the physician to send the prescription a second time. This occurred in three of the patients in our study who arrived at the pharmacy, only to find that their electronic prescription was not received. Sometimes, electronic prescriptions are received by pharmacies hours after submission due to network delays.28
 
Electronic prescription systems have other drawbacks that can serve as barriers to adoption. One concern for transitioning prescribers is the cost of implementation and maintenance,29 as well as the time needed to change over to the new system and train users.30 Some physicians believe new electronic health records with electronic prescribing capabilities to be unnecessarily complex, with too many steps required to accomplish simple tasks.31 Handwritten prescriptions are perceived by some prescribers to be simpler, quicker, and associated with fewer problems than electronic prescriptions.17,32 

Contributors to Electronic Prescribing Error

There are several sources that commonly contribute to the medication errors associated with electronic prescribing. Electronic prescribing software is susceptible to slowdowns, glitches, and delays in sending prescriptions.16 Limitations in compatibility between prescriber and pharmacy software due to lack of standardization could lead to errors in translation of information from one system to another,12,22,33-34 sometimes creating missing fields.21 At times, prescribers are at fault, unintentionally entering incorrect information due to fatigue, lack of concentration, or inexperience.22 Occasionally, an interaction between prescribers and the software can lead to error, due to usage of features such as auto-population of fields,21-22 default directions,21-22 automatically calculated doses,13,31 and dropdown menus.22 Each could lead to conflicting or incorrect information being entered into the prescription fields, especially if prescribers gloss over these details when in a hurry.13  

Reducing and Recovering from Error 

Both clinical decision support and pharmacies currently serve as barriers that prevent the patient from receiving an erroneous prescription. However, while clinical decision support may potentially help identify errors for the prescriber, poor layouts and overreliance on the system could prevent critical errors from being detected.35 On the other hand, experienced and trained pharmacists are adept at catching prescription errors, as they are familiar with common errors and have experience with contacting prescribers to correct these mistakes. Increased knowledge about medications and standard dosages, along with teamwork and communication, can facilitate the quick identification and correction of errors. However, interruptions (such as phone calls and pharmacy consultations) and time pressure (including waiting patients and backlogged prescriptions) both prevent quick recovery.35  
 
Thus, some precautions should be taken to reduce errors. First, as done in this study, prescribers should be trained on the pitfalls of electronic prescribing systems and be advised to remain vigilant while filling out prescriptions to minimize prescription errors at their source. Pharmacists should also be trained to identify and resolve common errors to protect patients from potential adverse outcomes.35 When possible, the electronic prescribing software should be continually updated to limit the potential for error. Notably, a study by Dhavle et al36 reported that the implementation of a watermark message in the “Notes” field of an electronic prescription led to fewer inappropriate uses of the field after three months. When all of these measures fail, it is important to have a backup system in place, such as precise discharge instructions. While one study found that the majority of prescribing errors were identified prior to reaching the patient, when these errors did reach the patient, 47 percent of patients were able to identify them.21 Though electronic prescribing may lead to fewer medication errors than paper prescribing, in the case that errors do occur and reach the patient, patients must be educated on their medications prior to discharge to potentially help them recognize these issues. This important step provides redundancy as a failsafe to increase medication safety.
 
In the NYUWH EP lab, we issue comprehensive discharge instructions that list the patient’s medications, including the dose, form, directions, and duration. Also stated for each medication are the dates and times of the last dose given and when the next dose should be taken, indicating the importance of timely receipt of the medications. Along with standard post-operative instructions to prevent complications, contact information for the operating physician is noted in the case of unexpected occurrences during recovery, including infection, bleeding, and failure to receive medications. Informing patients serves to mitigate prescription error, helping them properly receive their medications.  

Limitations

This study had several limitations. The investigation was completed at a single center utilizing just one electronic prescribing system. The three-month study period was relatively short in assessing a rare problem in data transmission failure. Combined with a limited number of patients, only a small number of incidents were observed. Further study is needed to confirm these findings in multiple centers and across multiple electronic prescribing platforms.
 
This study was also conducted immediately after the New York State mandate went into effect, so practitioners may have been relatively unfamiliar with the electronic prescribing software at the time.

Conclusion

This study identified a significant but infrequent issue with the electronic transmission of prescriptions. Transmission failures were likely due to both software and user errors. Discharge instructions were helpful in assuring that patients received their antibiotics even if the pharmacy initially failed to receive the patient’s prescription prior to the patient’s arrival. None of these electronic prescription errors resulted in adverse effects to the patients in the study. Physicians and practitioners at NYUWH were informed that electronically prescribed medications may not be received by their patients and were advised to confirm receipt of their patients’ prescriptions during follow-ups. Future studies should re-evaluate the rate of electronic prescription delivery failure at a later time to assess whether training, increased familiarity, and subsequent software updates diminish the rate of delivery failure.
 
Disclosures: The authors have no conflicts of interest to report regarding the content herein. 

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