Patient Safety Alert:  A notice from Surescripts

Title: Potential Patient Safety Issue (PPSI-3): Inaccurate Medication History (Surescripts)

Description: Surescripts notified us that they determined that some Medication History response messages sent to Modernizing Medicine, and thereafter to certain clients, may have contained inaccurate medication history data. Surescripts indicated that this issue has been resolved, and that they are not aware of any harm to any patient. In addition, Surescripts indicated that no protected health information (PHI) was exposed. 

Surescripts described the origin of the issue as follows:

Surescripts has determined that this issue occurred when certain pharmacies changed their pharmacy software system or aggregator which inadvertently assigned patient IDs that had previously been assigned to other patients. As a result, when a prescriber sent a Medication History request for one patient, the Surescripts pharmacy fill database may have sent a response that included medication history data for two patients. 

Scope of Impact: Surescripts has indicated that they believe this issue may have impacted medication history data sent between July 20 and October 29, 2020. As mentioned, although none of our ISC Software - Sammy clients were identified to be impacted by this issue, out of an abundance of caution and given the potential seriousness of this issue, we are providing this information to all clients.

Recommended Actions:  We strongly encourage all clients to carefully review and verify medication quantities and all other prescription information during the medication reconciliation process, and make any necessary corrections as you deem necessary. As always, clinicians should use sound professional and clinical judgment in all clinical decision making. We further strongly recommend that you review the medication history collected for patients between July 20 and October 29, 2020, and make any adjustments to prescriptions written during such period that may be appropriate based on the patient’s corrected medication history.

Surescripts Actions: Surescripts indicates that it identified this issue on October 28 while researching a Support case and that, immediately upon learning of the issue, Surescripts implemented a fix to exclude pharmacy fill data provided by pharmacies displaying this issue in any subsequent Medication History response messages. Surescripts has assured us that it is working to implement effective measures to eliminate any potential for this type of issue to occur in the future, including updating our certification guide and working with pharmacy customers to always provide unique patient IDs. 

Patient Safety Alert:  A notice from NewCrop

Subject Line: Patient Safety Alert: Inaccurate Prescription Instructions 

Dear Valued Client,

We recently received a message from our vendor, NewCrop, notifying us of a potential patient safety issue related to possible incomplete medication prescription instructions. We are providing the following information to all of our Sammy clients out of abundance of caution. NewCrop is also generating a list of impacted prescriptions, and we will provide affected practices with this additional information in a separate message after it becomes available.

Date Received from NewCrop: November 23, 2020

We have identified an issue that has caused some prescriptions to be e-prescribed omitting the quantity and form of the medication. Prescriptions missing this information will typically be rejected by the pharmacy. For instance, “Take 1 drop twice daily” might read “Take twice daily”.

However, as it is possible that a pharmacist may have dispensed an incomplete prescription, we have identified this as a Potential Patient Safety Issue.

This issue was resolved on 11/23 at 2:20pm CST, following code changes at 11/22 7:00pm CST. We are currently evaluating the scope of the issue, as it was triggered under specific circumstances. It appears to be tied to certain drug forms – notably not affecting tablets or capsules.

Prescription accuracy is our top priority, and we are closely reviewing the error that led to this issue reaching the production environment. We apologize for the inconvenience as this is likely to have resulted in failed or rejected prescriptions. 

Mitigation: NewCrop is currently working to generate a list of impacted prescriptions, and to narrow the time frame for this behavior. The pharmacy should 

have addressed the existing error prescriptions, and there should be no other steps necessary for the prescriber.

Modernizing Medicine strongly encourages all clients to carefully review and verify medication details and all other prescription information during the 

medication reconciliation process, and make any necessary corrections as you deem necessary. As always, clinicians should use sound professional 

and clinical judgment in all clinical decision making.  

Modernizing Medicine is committed to helping you deliver the safest care to all of your patients and we apologize for the inconvenience this may cause your practice. If you have any questions concerning this information, please contact our Support Team (support@icssoftware.net). 

Sincerely,

ICS Software Team

A Part of the Modernizing Medicine Family