Last year, pharmacies across the United States filled over 3.7 billion prescriptions. While the majority of these prescriptions were filled correctly, an unacceptably high number of patients weren’t as fortunate.

It’s a well known fact that pharmacy errors ranging from dispensing the wrong medication (or the right medication at the wrong dosage) to the failure to note dangerous drug interactions can have devastating consequences to patients.

In addition to these all too common mistakes, a recently published study in the Annals of Internal Medicine notes that many patients were also potentially harmed by another very serious — yet often overlooked — prescription error: the failure of pharmacies to follow orders to discontinue medication.

The researchers found that over 1 in 100 prescriptions that were ordered discontinued by physicians were still filled by pharmacies, presenting a very serious health risk to patients. Specifically, patients taking additional medications are at an increased risk of an adverse drug reaction, particularly if they are taking another medication to treat the same condition.

As if this wasn’t shocking enough, the researchers also determined that electronic medical records may be a big part of the problem.

The study indicates that many medical professionals are perhaps relying too much on the perceived accuracy of electronic medical records. For example, physicians might make an entry in a patient’s electronic file to discontinue a certain medication, taking it for granted that the pharmacy will automatically receive and carry out the order. Unfortunately, that is not always the case.

The researchers arrived at their conclusion by examining the electronic medical records of over 30,000 adult patients who had a drug used to treat a serious condition (cholesterol, diabetes, hypertension, etc.) discontinued by their physician.

Here, researchers found that while 83,900 medications were discontinued for these patients over a period of 12 months, 1,218 were still filled by pharmacies. In addition, they determined that 34 percent of these prescriptions presented a “high risk of potential adverse events,” including harmful reaction, drug interaction concerns and potentially imprecise lab tests.

While the researchers acknowledged that their study was certainly not without its limitations, it nevertheless raised awareness about the need for pharmacies and prescribing physicians to be more vigilant.

It also points out that, as the healthcare system moves more and more to electronic records, physicians must not abdicate their responsibility to ensure that patients are receiving the correct dosage of the correct medication for the correct length of time. No computerized system can relieve healthcare professionals of their duty to provide quality care and guard against the harmful and potentially fatal consequences resulting from preventable error.

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Source: Scientific American, “Pharmacies dispense meds even after docs stop prescription,” Katherine Harmon, Nov. 19, 2012