Potential Patient Safety Alert: Medication Favorites

Potential Patient Safety Alert: Medication Favorites (18-Apr-2019)

Office Practicum is committed to patient safety, and as such we prioritize concerns that may impact safe use of software to deliver care. Safe medication prescribing is a key component of providing safe care. OP will be implementing 4 changes to address these concerns:

  1. Re-deploying a safety check in our e-prescribing processing software so that no potentially unsafe prescription can reach the pharmacy and will be failed. (user action required: none, impact: all customers)
  2. Changes to OP that streamline your ability to address medication favorites which are not conformant to the current pharmacy database. (update information below)
  3. Changes to OP that identify potentially at risk prescriptions and prevent you from sending from OP. (update information below)
  4. Changes to OP so saved favorites can no longer be edited in a way that impacts NDC/name/form/strength (already deployed as OP 14.9.29 and OP 14.10.6)

In order to minimize interruption in your practice’s ePrescribing, please review the urgent information below.

As you should be aware, it has recently come to Office Practicum’s attention that some customers were editing favorite medications in a way that created a mismatch between the NDC and the drug description itself.  An NDC is an ID number that uniquely identifies a prescription’s medication name/dose/strength/ manufacturer. Best practices have always been that medications should be added to the Favorites list by using the Master List, which pulls NDC and drug name/strength/form details directly from the integrated drug database. For ease of updating favorites, Office Practicum had allowed editing of saved favorites, permitting customers to unknowingly create mismatched favorites.

This was particularly concerning when some users inadvertently changed the name/strength/form for controlled substances used for ADD/ADHD. Some practices have favorites that have different strengths of a medication all inappropriately linked to the same NDC. (For example, Adderall XR comes in different strengths, all of which should have a different NDC). The prescriber thinks in “words” (I want Adderall XR 10 mg), while the pharmacy systems think in NDC (the prescriber sent the NDC for Adderall XR 30 mg). Patients could potentially be getting a different strength/form (or potentially even medication) than what the prescriber intended. There is a “safety check” at the pharmacy level, where pharmacists may notice this mismatch, which is what brought this discrepancy to our attention.

PLEASE: go to your favorites (Utilities/Manage Clinical Features/Medication Favorites) and look at these high risk medications. If you have NDC numbers that are the same for more than one drug, this is an error and needs to be addressed immediately. Each medication (drug name, form, strength) should have a unique NDC. Effective 4/19/19 mismatched prescriptions will fail.

It may be appropriate for a single drug/single NDC to have more than one favorite.  For example, banded weight dosing for Tamiflu has the same NDC attached to different templates.  However, the Drug/Form/Strength is also the same:


In this example, there are multiple Favorites using NDC 00004082205, but they all reference Tamiflu Suspension, 6 mg/ml.  These are likely to be appropriate.

You can identify problematic Favorites by seeing the same NDC attached to drugs that have different Drug/Form/Strengths.

In this case, the same NDC number (33358029440) is attached to two different drugs: the 10 mg and 20 mg forms of prednisone.  Only one can be correct.

Office Practicum has instituted a patch so that in the future, favorites cannot be edited to perpetuate this problem. (Cloud clients already have this change. We encourage users to update to OP 14.9.30 or OP 14.10.8 as soon as it is available so that they also have this improvement, which will reduce the impact of failed prescriptions.) Unfortunately, it is impossible to know which favorites individual practices had inadvertently changed, so we must implement additional rigorous safety checks. You will receive a follow-up communication when these OP versions are available and as always the detailed release notes to review included changes.

In order to prevent mismatched medications from reaching the pharmacy and creating potential safety issues, Office Practicum is adding a “safety check” every time you prescribe a medication that you choose from a favorite, or renew from the patient’s medication list (where you might have used a favorite initially.) This safety check will look at the updated drug database and compare what the drug database name/form/strength is for the NDC. If they do not match what you are currently attempting to prescribe (allowing for case sensitivity and spaces), OP will fail the prescription.

Prescriptions go from your OP instance to another piece of software in OP Cloud called OPEN/Crab Key before being forwarded through the e-prescribing network (Surescripts) to the pharmacy. Since all prescriptions that are e-prescribed go through OPEN/Crab Key, OPEN/Crab Key is where the final safety check occurs.

Earlier this week, Office Practicum updated OPEN to include this safety check, and thousands of prescriptions failed. We apologize for the unintended consequence created by attempting to protect potentially unsafe prescriptions. We have learned that since many of us created medication favorites, the standard descriptions for medications have changed. For example, what used to be called “suspension for reconstitution” has been changed to “suspension, reconstituted, oral.” Unfortunately, the computer cannot decide what constitutes an insignificant mismatch and what changes the true meaning of the prescription.  For example, albuterol solution comes both in both a “solution for nebulizer” which you mix with saline and a “vial for nebulizer,” which translates to premixed vials. The prescription instructions for families are distinctly different for those medications. 

We have updated OPEN/Crab Key to allow for small non-material discrepancies in spaces and upper/lower case, but our determination is that there is no other safe way to allow additional kinds of differences to be sent to the pharmacy. Depending on when you created your favorites, many of them may no longer be valid. In addition, any medication you have on a patient’s medication list that was created by initially using an out-of-date favorite may be impacted if you attempt to renew/refill. While we recognize and apologize for the burden on our customer community, patient safety must be our first priority. As clinicians we are trained to “first do no harm.” OP must support that commitment and the OPEN/Crab Key safety check will be re-deployed on 4/18/19 at midnight.

Do you have to do anything to update your OPEN/Crab Key? No. Office Practicum will be deploying the safety-checking version of OPEN/Crab Key 4/18/19 at midnight. Going forward, all prescriptions being sent from OP practices will go through this safety check. All of our customers, whether cloud or on-premise server, can have full confidence that you are sending safe prescriptions.

We realize this is going to be a significant burden on practices to clean up all of their favorites. 

While someone in your practice is doing this work, you may want to tell your prescribing clinicians to initiate all medications from the Master List. In order to assist you in this process, the “Validate NDC button” is being updated to include the same safety check. This functionality will be available with OP update OP 14.9.29 and OP 14.10.8.

Starting with versions OP 14.9.29 and OP 14.10.8 and going forward, whenever you select a medication from the favorites list, or renew a prescription on the patient’s medication list, OP will do a safety check internally, and if there is a mismatch, will tell you that this is not able to be safely prescribed. It will behave in the same way the prescriptions currently do if you attempt to send a prescription without a valid NDC. This will prompt the prescriber to choose a medication that has a correctly matched NDC and description before it leaves OP. Using this validation check inside OP, will prevent numerous failures after the user hits send (as the prescription passes through OPEN/Crab Key.) 

Why can’t OP just ask me to update my favorites if they find this mismatch or automatically fix them for me? We have determined that changing the name/strength/form may have implications for changing the sig, such as different strengths leading to different dose amounts or frequency. In an abundance of caution, we do not feel it is safe for OP to do this behind the scenes for the prescriber. In addition, we determined that it is likewise risky to give that opportunity to every user in the context of writing a prescription for one patient. When you are choosing from the favorite, it has not yet been applied to that particular patient. If we give you a chance to “fix on the fly” it may have implications on the favorite itself, which is not appropriate for other patients. 

How can I start cleaning up my favorites even if I don’t have the latest version?

If you know that you likely have some “old favorites” with out of date descriptions (such as albuterol solution below), choose the edit button:

And use the functionality to go to the master list:

You may find that the name doesn’t even map to something that you were intending:

You have to change the search name, in this case just “albuterol”

And find the medication that you intended on the favorite and re-choose from the master list:

Which will update your favorite to the most up-to-date drug details (noticed the difference from above) so that your NDC and description will be matched appropriately and will not be able to be edited going forward.

Why doesn’t the Validate NDC button fix all this for me? 

In the current build of OP, the “Validate NDC” button only confirms that each medication currently has a valid NDC; it does not confirm that the medication you intend to prescribe currently has the correct NDC to match your description. OP can’t safely know which of the favorites have insignificant mismatches, and which of the favorites have significant implications for patients. In addition, OP can’t know whether the original intent of the prescription (including the liquid calculations, rounding rules and sig) was intended to be for the wording or the NDC.   

How do I fix it when I see an invalid NDC (red highlight)?


How can I minimize the impact to my practice?

  • Communicate this information to your entire practice team
  • Advise prescribing clinicians to consider prescribing from the Master List until a Favorites Champion can be identified and the Favorites list has been validated and updated
  • Use caution when renewing a prescription from within the patient’s medication list, as it may have been created from a favorite that has invalid NDC/descriptions or may contain name/form/strength descriptions that are no longer valid
  • Update your instance of OP as soon as possible so you can implement the improvements in the Validate NDC for favorites and the OP validation/safety check. This will make sure the safety check occurs prior to hitting send (thereby minimizing the number of failed prescriptions). Additional communication about cloud and on-premise update availability will be sent as soon as possible.

We know that this is disruptive to your prescribing workflow and apologize for the hardship it causes. Thank you for joining OP in our commitment to making patient safety a priority. Feel free to email me directly with additional questions or concerns that are not already answered by this or prior communications, or can be found on our Help center.

With deep appreciation for all you do for patients and families, 

Susan J. Kressly, MD, FAAP