American Society of Health-System Pharmacists

Five Things Physicians and Patients Should Question

Released June 1, 2017; #1, 3 & 4 updated June 20, 2019, #1–4 updated July 28, 2021

  1. 1

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

    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. New medications should not be initiated without taking into consideration patient adherence with their pre-existing medication and whether their current dose is effective at controlling/treating symptoms. Incorporating Comprehensive Medication Management (CMM) services can assist in meeting the recommendations. CMM is a patient care service where medication-use experts collaborate with patients, their healthcare team, families, and caregivers to review and ensure treatment plans are optimal, with respect to patients’ beliefs, values, autonomy, and agency.

  2. 2

    Do not prescribe or indefinitely continue medications for patients on five or more medications, without a comprehensive medication review including prescription and over-the-counter medications and dietary supplements, to determine whether any of the medications or supplements can be discontinued and assure all medications to be taken by the patient are optimized for the patient’s specific medical and social conditions.

    Studies have shown that patients taking five or more medications often find it difficult to understand and adhere to complex medication regimens. Comprehensive Medication Management services where medication-use experts review all medications and medical conditions in collaboration with patients, their healthcare team, families, and caregivers; to ensure treatment plans are optimal, all medications are needed, and the plan respects patients’ beliefs, values, autonomy, and agency; should be conducted at periodic intervals appropriate for the patient, or at a minimum annually.

  3. 3

    Do not continue medications based solely on the medication or dispensing 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 primary source of truth, with medical records and pharmacy refill information as secondary sources, when taking the medication history. The patient or caregiver should be interviewed by someone with medication-use expertise, ideally a pharmacist, and medications should be continued only if there is an associated active medical 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. A medication-use expert should lead medication reconciliation processes during high-risk transitions of care to assure correct and optimal therapy for the patient.

  4. 4

    Do not prescribe patients medications during care transitions (i.e. hospital discharge, long term care facility, between different healthcare professionals, etc.) without verifying that these all medications have an indication and are still needed, and that discharge any new medications will not result in duplication, drug interactions, or adverse events.

    Treatments and procedures during a hospitalization or other institutionalized stay 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 admission in light of the patient’s current state. Transitions of care in non-institutional settings, such as patient transitioning among multiple healthcare professional visits should also be considered a transition of care risk. Unnecessary medications should be discontinued, duplicate or overlapping therapies should be changed, and the specific changes should be clearly communicated to the patient/caregiver and the patient’s healthcare team (i.e. primary care clinician, specialists, the patient’s pharmacy). The Joint Commission recommends a thorough medication review at admission and discharge to prevent any unnecessary medications being continued. Medication-use experts should partner with patients and the inter-professional care team to identify, assess, and resolve barriers to medication access, adherence, and health literacy to establish consistent and sustainable models for seamless transitions of care.

  5. 5

    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.

    The Patient Care Process for delivering Comprehensive Medication Management (CMM): Optimizing Medication Use in Patient-Centered, Team-Based Care Settings. CMM in Primary Care Research Team. July 2018. Available at http://www.accp.com/cmm_care_process

    ASHP Practice Advancement Initiative 2030: New recommendations for advancing pharmacy practice in health systems. Am J Health-Sys Pharm. 2020; 77:113-122.

  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.

    The Patient Care Process for delivering Comprehensive Medication Management (CMM): Optimizing Medication Use in Patient-Centered, Team-Based Care Settings. CMM in
    Primary Care Research Team. July 2018. Available at http://www.accp.com/cmm_care_process

    ASHP Practice Advancement Initiative 2030: New recommendations for advancing pharmacy practice in health systems. Am J Health-Sys Pharm. 2020; 77:113-122.

  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. www.jointcommission.org/standards_information/npsgs.aspx (accessed 2017 Jan 21).

    ASHP Practice Advancement Initiative 2030: New recommendations for advancing pharmacy practice in health systems. Am J Health-Sys Pharm. 2020; 77:113-122.

  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