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a clinical pharmacist identifing medication. Looking at pills and checking chart.
Uncovering a Health Record Error With a Nationwide Impact

While rounding with an inpatient team, a clinical pharmacist identified that a patient’s medication list contained two medications to prevent stroke and heart attack, ticagrelor and atorvastatin, with no apparent indication. She verified the patient was not on these medications and had them removed from the medication list so they would not be prescribed at discharge or in the future. The following day, the pharmacist identified a second inpatient whose medication list contained three antihypertensive medications and one contraceptive medication, and again validated that they were not prescribed for this patient and they did not have any medical conditions requiring them. Since medications were automatically populating to patients’ medical records, the pharmacist escalated the issue to the EHR vendor, who discovered that the company that provided the EHR electronic pharmacy network had experienced a temporary interface issue the day before, during which potentially erroneous information was provided over about 24 hours. Upon uncovering the error, the pharmacy network notified clients nationwide about it. The pharmacist’s quick response in discovering a safety concern and her vigilance in escalating this situation helped mitigate a serious risk of harm to patients across the country.

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