Many Pharmacists Likely to Fill Dangerous Prescriptions

An Expert Interview With James Hoehns, PharmD

Alice Goodman

October 25, 2011

October 25, 2011 (Pittsburgh, Pennsylvania) — Editor’s Note: A large survey presented at the American College of Clinical Pharmacy (ACCP) 2011 Annual Meeting held here October 16-19, 2011, showed that more than 50% of pharmacists would fill prescriptions with an apparent overdosage when the prescribing physician verified and approved the prescription. Community pharmacists were somewhat more likely than hospital pharmacists to fill an incorrect and possibly dangerous prescription under these circumstances, but it is not clear why this is so. Medscape Medical News spoke with James Hoehns, PharmD, faculty member at the University of Iowa College of Pharmacy, Iowa City, about this study.

Medscape: What was the genesis of this survey?

Dr. Hoehns: This survey was led by Colleen Kann during her pharmacy residency at the University of Iowa under my tutelage. Over the years, I had become aware of occasional inappropriate prescriptions being filled. I am one pharmacist, so it is unclear how often this occurs. We designed a survey to probe attitudes and decision-making among pharmacists when faced with an inappropriate prescription that is verified by the prescribing doctor. To be clear, pharmacists (with prescriber input) resolve the vast majority of prescription-related problems that they identify. Our survey addresses a scenario that is infrequent but has potential for significant harm to patients. The study has several limitations and does not capture any patient counseling a pharmacist would provide.

Medscape: What did the survey entail?

Dr. Hoehns: We sent the survey to a group of pharmacists in the Midwest. We received 599 responses. About 60% were female, about 40% had worked for less than 10 years, and about one third had worked for more than 20 years.

We presented them with 5 hypothetical clinical scenarios:

  1. Appropriate prescription of lithium for bipolar disorder.

  2. Inappropriate prescription of digoxin for new diagnosis of atrial fibrillation.

  3. Inappropriate prescription of methotrexate for a flare of rheumatoid arthritis.

  4. Inappropriate prescription of fentanyl patch for pain from a recent knee replacement in patients who had taken Vicodin for 7 days previously.

  5. Prescription of Imitrex for migraine in patients with a cardiovascular contraindication.

We asked what they would do if all of these prescriptions were verified by the prescribing doctor after being contacted by the pharmacist.

Medscape: What did you find?

Dr. Hoehns: More than 95% of pharmacists would have filled the lithium prescription, which was a correct action. However, 18.5% would have filled the incorrect digoxin prescription, 17% the toxic methotrexate prescription, and 38% the fentanyl patch. For Imitrex, 54.1% would have filled the prescription.

Medscape: These were hypothetical situations. Did you ask about real-life practice?

Dr. Hoehns: Yes, we asked how many respondents had ever filled an inappropriate and potentially dangerous prescription under similar circumstances (ie, after verifying the prescription with the provider), and 43% recalled doing this. When asked the reasons for this, 74% deferred to the prescribing doctor because they assumed that he/she knew more about the particular patient and situation than they did.

Medscape: What are the implications of this survey?

Dr. Hoehns: We found that about 50% to 60% of pharmacists believed that they could benefit from more training on how to handle patient safety concerns related to inappropriate prescriptions. Many respondents wrote in comments about that they were pleased we were analyzing this question. In fact, as a result of this survey, I have included this topic in a session I teach that touches on medicolegal ramifications and how to deal with inappropriate prescriptions. I’ve gotten good feedback from students who are happy to learn about this very real question that could come up.

Drs. Hoehns and Kann have disclosed no relevant financial relationships.

American College of Clinical Pharmacy (ACCP) 2011 Annual Meeting; Abstract #173. Presented on October 18, 2011.

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