American Society of Health-System Pharmacists

Five Things Physicians and Patients Should Question

Released June 1, 2017

  1. 1

    Do not initiate medications to treat symptoms, adverse events, or side effects without determining if an existing therapy or lack of adherence is the cause, and whether a dosage reduction, discontinuation of a medication, or another medication is warranted.

    New medications should not be initiated without taking into consideration patient compliance with their pre-existing medication and whether their current dose is effective at controlling/treating symptoms. Medications are often prescribed to treat symptoms that are really side effects of other medications without determining if the pre-existing medication is truly needed or could be discontinued.

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    Do not prescribe medications for patients on five or more medications, or continue medications indefinitely, without a comprehensive review of their existing medications, including over-the-counter medications and dietary supplements, to determine whether any of the medications or supplements should or can be discontinued.

    Studies have shown that patients taking five or more medications often find it difficult to understand and adhere to complex medication regimens. A comprehensive review, including medical conditions, should be done at periodic intervals, at least annually, to determine if the medications are still needed and if any medications can be discontinued.

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    Do not continue medications based solely on the medication history unless the history has been verified with the patient by a medication-use expert (e.g., a pharmacist) and the need for continued therapy has been established.

    The patient or caregiver should be the sole source of truth when taking the medication history. The patient or caregiver should be interviewed by someone with medication-use knowledge, ideally a pharmacist, and medications should be continued only if there is an associated patient indication. If a pharmacist is not available, then at a minimum, the healthcare worker taking the history should have access to robust drug information resources. The history should include the drug name, dose, units, frequency, and the last dose taken; and indication if available.

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    Do not prescribe patients medications at discharge that they were on prior to admission without verifying that these medications are still needed and that the discharge medications will not result in duplication, drug interactions, or adverse events.

    Treatments and procedures during a hospitalization may impact a patient’s ongoing need for a medication they were receiving prior to admission. Care should be taken at discharge to consider each medication taken prior to hospitalization in light of the patient’s current state. Unnecessary medications should be discontinued, duplicate or overlapping therapies should be changed, and the specific changes should be clearly communicated to the patient. The Joint Commission recommends a thorough medication review at admission and discharge to prevent any unnecessary medications being continued.

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    Do not prescribe or administer oral liquid medications using teaspoon or tablespoon for measurement; use only milliliters (mL) when measuring with an approved dosing device (e.g., medication cup or oral syringe).

    Serious medication errors, including patient deaths, have occurred because oral liquids are prescribed and/or administered using English measurement units such as the teaspoon or tablespoon. For medical professionals, best practice is using units and volume when prescribing a single-agent liquid medication, to be sure the dose is clear; but for administering, use only mL for measuring the amount. Safety organizations and agencies such as the Centers for Disease Control and Prevention (CDC) and the Institute for Safe Medication Practices (ISMP) have recommended using only the metric system units (e.g., mL) for measurement and using a measuring device that contains only metric markings. Prescribing using the metric system and dispensing with a metric measuring device will help avoid these preventable errors.

These items are provided solely for informational purposes and are not intended as a substitute for consultation with a medical professional. Patients with any specific questions about the items on this list or their individual situation should consult their physician.

ASHP represents pharmacists who serve as patient care providers in acute and ambulatory settings. The organization’s more than 43,000 members include pharmacists, student pharmacists, and pharmacy technicians. For over 70 years, ASHP has been on the forefront of efforts to improve medication use and enhance patient safety. ASHP’s vision is that medication use will be optimal, safe, and effective for all people all of the time.

How This List Was Created

A task force made up of pharmacists from all practice settings was formed. The task force was oriented to the criteria used to establish Choosing Wisely lists and already established recommendations. Based on this information and on their knowledge of how medications are prescribed, dispensed, and administered, the task force developed an initial list of recommendations. Over time this list was vetted, evaluated, researched, and referenced. Through a consensus process over time the list was prioritized down to a total of five recommendations. This list was approved by the ASHP Board of Directors.

Sources

  1. Schiff GD, et al. Promoting more conservative prescribing. JAMA 2009;301:865-7.

    Schiff GD, et al. Principles of conservative prescribing. Arch Intern Med. 2011;171:1433-40.

    Shane, R and Abramowitz, PW. Choosing Wisely: Pharmacy’s role in effective use of medications. Am J Health-Syst Pharm. 2015; 72:1529-30. doi.org/10.2146/ajhp150324.

  2. Maher RL, et al. Clinical consequences of polypharmacy in elderly. Expert Opin Drug Saf. 2014; 13: 57-65. dx.doi.org/10.1517/14740338.2013.827660

    Gorard, DA. Escalating polypharmacy. QJM 2006; 99 (11): 797-800. doi.org/10.1093/qjmed/hcl109

    Lehnbom, EC, et al. Impact of medication reconciliation and review on clinical outcomes. Ann Pharmacother. 2014;48:1298-1312.

    Shane, R and Abramowitz, PW. Choosing Wisely: Pharmacy’s role in effective use of medications. Am J Health-Syst Pharm. 2015; 72:1529-30. doi.org/10.2146/ajhp150324.

  3. ASHP statement on the role of the pharmacist in medication reconciliation [Internet]. Available from: www.ashp.org/DocLibrary/BestPractices/SpecificStMedRec.aspx

    Najafzadeh M, et al. Economic value of pharmacist-led medication reconciliation for reducing medication errors after hospital discharge. Am J Manag Care 2016;22:654-61.

    Varkey, P, et al. Multidisciplinary approach to inpatient medication reconciliation in an academic setting. Am J Health-Syst Pharm. 2007; 64:850-5.

    Lehnbom, EC, et al. Impact of medication reconciliation and review on clinical outcomes. Ann Pharmacother. 2014; 48:1298-1312.

    The Joint Commission. 2017 National Patient Safety Goals [Internet; cited 2017 Jan 21]. Available from: www.jointcommission.org/standards_information/npsgs.aspx

  4. Varkey, P, et al. Multidisciplinary approach to inpatient medication reconciliation in an academic setting. Am J Health-Syst Pharm. 2007; 64:850-5.

    Najafzadeh M, et al. Economic value of pharmacist-led medication reconciliation for reducing medication errors after hospital discharge. Am J Manag Care 2016; 22:654-61.

    Lehnbom, EC, et al. Impact of medication reconciliation and review on clinical outcomes. Ann Pharmacother. 2014; 48:1298-1312.

    The Joint Commission. 2017 National Patient Safety Goals [Internet; cited 2017 Jan 21]. Available from: www.jointcommission.org/standards_information/npsgs.aspx

  5. CDC. Protect initiative [Internet. Cited 2017 Jan 5]. Available from: www.cdc.gov/medicationsafety/campaign_initiatives.html

    ISMP Nan-alert 2015 [Internet; cited 2017 Jan 5]. Available from: www.ismp.org/NAN/files/NAN-20150630.pdf

    Traynor, K. Standardize units for dosing liquid oral prescription medicines, task group says. Am J Health-Syst Pharm. 2014; 71:1062-4. https://doi.org/10.2146/news140045