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Clinical Crossroads |

A 40-Year-Old Woman Who Noticed a Medication Error

David W. Bates, MD, MSc, Discussant
JAMA. 2001;285(24):3134-3140. doi:10.1001/jama.285.24.3134.
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DR AUDET: Ms K is a 40-year-old woman who found an error with her prescribed medications. She was diagnosed with HIV infection in 1996 and has taken several different drug regimens. Despite the complexity of her drug program, Ms K has been able to manage it well. She has taken an active role in understanding the benefits of her medications and has not had major adverse effects.

Ms K had asked that refills for her prescriptions be called in to her pharmacy. When the time came to take her newly filled prescriptions, she noted that 2 of the drugs were unfamiliar to her, and that 2 of her HIV drugs were missing.

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Figure. Prescription Refill Process and New Prescription Process in an Outpatient Setting
Graphic Jump Location
A basic tenet of quality improvement is that it is helpful to reduce the number of steps in a process, especially handoffs. This figure displays the medication process for refills (A) and new prescriptions (B) in the ambulatory setting using the current routing approach and then with electronic prescribing. In both instances, electronic prescribing substantially simplifies the process. In addition, making the process electronic allows introduction of forcing functions (eg, a drug name, dose, route, and frequency must be specified for medications, or the person refilling the medication must check the prior medication list) and decision support (eg, checks for drug allergies and drug-drug interactions, among others).



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