e-Prescribing: Some Considerations

I’m always in the mood for stories, which is why I love the Cases and Commentaries section on the AHRQ WebM&M site. There’re a bunch of February posts up there but the one that caught my eye was one titled E-prescribing: E for Error?

The case involved a 63 year old man who went in to see his primary care physician. He was receiving psychotherapy, but was still prone to anxiety. The PCP prescribed him alprazolam for the anxiety. Since the clinic had just implemented a new e-prescribing system, the doctor assured the patient that he didn’t need a paper prescription and just needed to show up at pharmacy and pick up his order.

So far so good.

Back at the doctor’s office, a nurse entered the presribed medication into the practice’s shiny new system, except that she inadvertently added an order of atenolol, intended for a different patient, to this patient’s order. She soon realized her mistake and deleted the atenolol order.

When the patient went to the pharmacy, he was given both the alprazolam and the atenolol, which he thought was odd, since he had been prescribed only one medication. However, he just went ahead with taking both medications per the directions handed to him by the pharmacist, and it was only a few days later, during an appointment with a cardiologist that the mistaken atenolol addition was finally identified.

Fortunately, the patient lived to tell the tale, which we all know is not the outcome in some sad cases. Elisa W. Ashton, the author of this Cases and Commentaries piece, has some great points listed as her takeaways from this case. Here are mine:

It’s too soon to say goodbye to paper. I worry about trees more than the average Jane, but if there’s a ever a case to be made for a paper prescription, here it is. A paper prescription would’ve shown up the double prescription both to the nurse, as well as the patient, making it less likely to make it to the pharmacy.

It’s not clear who/what failed. Did the nurse realize delete the wrong entry only after she transmitted the patient’s prescription? Did the prescription software trule delete the medication or simply mark it as flagged for deletion?

– This accident happened on a newish system, perhaps users were not as familiar with it as they should have been.

If you think something’s odd about your prescription, speak up. As patients many of us tend to assume that doctors know best. However, doctors are as human as everyone else, no matter how many initials tag along before or after their names. You don’t have to be obnoxious about it, it’s perfectly fine to verify politely with your doctor’s office if the additional (or missing) medications are necessary.

– Bravo to the eagle-eyed cardiologist! It was great someone caught this error in time, though I would much prefer that some kind of check system be built into the e-prescription system to prevent errors of this sort.

Go check out the post on AHRQ.

About the author


Priya Ramachandran

Priya Ramachandran is a Maryland based freelance writer. In a former life, she wrote software code and managed Sarbanes Oxley related audits for IT departments. She now enjoys writing about healthcare, science and technology.


  • The biggest problem I see in the above case is that the doctor should have ePrescribed right at the point of care. If he had a simple mobile application that connected him to his ePrescribing application, then he would have been much more likely to have entered the correct drug in the first place. Plus, if he did make a mistake entering the drug he could have informed the patient to make sure they only got the one drug that was appropriate.

    It’s amazing how many errors are caused by later data entry as opposed to data entered at the point of care.

  • One of the biggest gaps in the workflow assessments that many EMR/EHR vendors perform is the procedures for error handling. In working with our clients, especially those that have contracted us to “fix” their new EMR/EHR workflow, we identify the common “what-ifs”. Sending the wrong e-prescription is top of this list and we train staff to CALL the pharmacy and verify that errors are corrected.

    EMR/EHR are wonderful tools, but as long as humans are using them, it isn’t practical to design workflows that don’t account for human error.

    As a side note, it’s amazing how accuracy improves when the user has to perform a manual step to correct an error instead of just clicking a button to delete the mistake.

  • Thanks for posting this article. “Is it too soon to say goodbye to paper?” I don’t think so. It’s sad what happened in this case, but mistakes happen with paper prescriptions too. For one, EHRs & eprescribing have made Rxs vastly easier to read. I come from a behavioral health background, which is far behind HIT, so I’ve heard all the reasons for clinging to paper. I agree with Anna, and have repeated the same message infinitum: there will also be humar error. IMHO, time is better spent discussing how to reduce or account for human error in EHRs, rather than discussing whether to move away from paper.

  • I wonder how a non-prescribing nurse was able to electronically sign the prescription. I would think the prescribing doctor would have to do that.

  • This actually makes a lot of sense to me. Whenever you transmit an electronic prescription, you cannot delete the prescription on the pharmacy’s end, only yours. So when you make a mistake and delete a scrip for drug X that has already been sent in, it doesn’t delete it from the computer that is read by the pharmacy. A lot of prescribing providers don’t know this. The only way to be sure it’s deleted is by calling the pharmacy and instructing them to discontinue the scrip you sent incorrectly. The same goes when you want to change a dose of medication. The original dose stays in the pharmacy and the computer shows 2 scrips on file at different doses. I usually add a text message in the comments asking them to discontinue all prior doses of the same medication.

  • >>> For one, EHRs & eprescribing have made Rxs vastly easier to read.

    Not my prescriptions- I send all of my prescriptions to the printer. They are typed, and the only thing written is my standard, authentic signature.

    The main reason why eRx is being pushed so much is because Obama’s gulfing buddy, Glen Tullman, is the CEO of Allscripts which stands to benefit from the increased bureaucracy.


  • Every good process needs a check and balance. Once a written prescription is provided to a patient, there is no way to stop the prescription from being filled. The physician doesn’t even know where the prescription is being filled or even if it was filled. At least with eprescribe, you know where the prescription was sent and can find out if it was filled. If a nurse is going to enter a prescription, then the physician should be the one to check it and send it. If an incorrect prescription is ever sent or written to a patient, the patient must be called, so that they do not take the medication. This is not a technology issue, it is a process issue.

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