Description of Event or Problem · 0
ENTERED FROM MED SAFETY QUESTION WITH PERMISSION OF RESPONDENT FDA: YES X NO YES, IT'S FINE TO SHARE MY CONTACT INFO. GLAD TO DO ANYTHING I CAN TO HELP. AND YES, I UNDERSTAND THAT ISMP LACKS ANY REGULATORY "TEETH BUT I THINK YOUR ORGANIZATION HAS BOTH A COMPELLING MANDATE THAT IS PURSUED CONSISTENTLY AND A VERY REAL AMOUNT OF I DUNNO, 'CLOUT' IN THESE ISSUES. YOU'RE IN A BETTER POSITION THAN I OR MAYBE ANY OTHER ORGANIZATION TO WORK ON THIS PROBLEM. THANK YOU FOR BEING WILLING TO DISCUSS IT WITH (B)(6). I'M A FAN OF MANY OF THEIR PRODUCTS SO I HAVE HOPES THEY WILL TAKE THIS SERIOUSLY. SCREENSHOTS OF TRUNCATED MEDICATION NAMES, AS IMPORTED TO OUR SYSTEM FROM MEDISPAN FOLLOW. I CAN PROVIDE A LOT MORE, IF REQUESTED. NOT TO BEAT A DEAD HORSE, BUT THIS CAN CREATE CONFUSION FOR PATIENTS TOO. I'VE HAD PATIENTS INSIST THAT THE NEW MEDICATION (METOPROLOL, PER THE LABEL) WAS DIFFERENT FROM WHAT THEY GOT PREVIOUSLY (LABELED 'METOPROL'). THIS CREATES A DIFFICULT & UNNECESSARY CONVERSATION AND IMPAIRS THE PATIENT'S TRUST IN BOTH THEIR THERAPY AND THEIR PHARMACIST. NOT GOOD. WE (Y'ALL AT ISMP ESPECIALLY) SPEND A LOT OF ATTENTION TO TALL MAN LETTERING AND OTHER STRATEGIES TO REDUCE CONFUSION, AND IN THE PAST I HAVE SEEN DRUG COMPANIES FORCED TO ACTUALLY CHANGE THE NAME OF A DRUG ON THE MARKET BECAUSE IT WAS TOO CLOSE TO ANOTHER EXISTING DRUG'S NAME. IN THAT CONTEXT, IT SEEMS WRONG TO ALLOW SOMEBODY'S SOFTWARE TO DICTATE DRUG NAMES ON PHARMACY LABELS. IT SHOULD BE AN EASY FIX COMPARED TO CHANGING THE NAME OF A DRUG ALREADY ON THE MARKET! YOU MIGHT POINT OUT THAT SOME OF THE 'ABBREVIATED' ONES ARE ACTUALLY LONGER THAN OTHERS THAT DO NOT GET ABBREVIATED. MONTELUKAST IS 11 CHARACTERS. 'METOPROL' IS JUST 8. SO WHATEVER ALGORITHM IS DOING IT, IS NOT EVEN A VERY GOOD ONE. LET ME KNOW IF YOU NEED MORE OF THESE: (B)(6), PHARMD NIGHTINGALE DRUG, (B)(6) FROM: (B)(6) SENT: THURSDAY, JULY 27, 2023 8:42 AM TO: (B)(6) CC: INFO SUBJECT: ISMP RESPONSE: MEDISPAN DATA UPLOADS TO PMS DEAR MATTHEW, THANK YOU FOR YOUR INQUIRY REGARDING TRUNCATED MEDICATION NAMES WITHIN YOUR PHARMACY MANAGEMENT SOFTWARE. ISMP DOES NOT SUPPORT ABBREVIATING MEDICATION NAMES TO THE MAXIMUM EXTENT POSSIBLE, ACKNOWLEDGING DRUG NAME FIELD CONSTRAINTS. THE ISMP GUIDELINES FOR SAFE ELECTRONIC COMMUNICATION OF MEDICATION INFORMATION DOCUMENT OUTLINES THIS AND OTHER RECOMMENDATIONS [HTTPS://WWW.ISMP.ORG/SYSTEM/FILES/RESOURCES/2019-03/ELECTRONIC-GUIDELINES-2019.PDF; (HTTPS:WWW.ISMP.ORG/SYSTEM/FILES/RESOURCES/2019-03/ELECTRONIC-GUIDELINES-2019.PDF)] ISMP DOES HAVE REGULAR MEETINGS WITH THE VENDOR (B)(6) WHO APPEARS TO OFFER THE MEDISPAN DRUG LIBRARY FILES. WE WOULD LIKE TO INCLUDE THIS ISSUE IN OUR NEXT CALL. DO YOU HAVE SOME DE-IDENTIFIED SCREENSHOTS WHICH COULD BETTER ILLUSTRATE THIS PHENOMENA AND DISCUSS WITH THE VENDOR? BECAUSE ISMP IS NOT A LEGAL, REGULATORY, OR ACCREDITING AUTHORITY, HEALTH INFORMATION TECHNOLOGY VENDORS AND FACILITIES MAY OR MAY NOT CHOOSE TO FOLLOW THESE RECOMMENDATIONS. ULTIMATELY, THIS PROBLEM APPEARS TO BE AN INTEGRATION OF FACILITY SPECIFIC PHARMACY MANAGEMENT SOFTWARE WITH DRUG FILE MANAGEMENT FILES WHICH IS BEYOND THE DIRECT CONTROL OF ISMP, BUT WE WILL INCLUDE THIS TOPIC IN OUR DISCUSSION. THIS REPORT WILL BE ENTERED INTO THE ISMP NATIONAL MEDICATION ERRORS REPORTING PROGRAM (ISMP MERP) DATABASE AND WILL BE KEPT CONFIDENTIAL IN ACCORDANCE WITH ISMP'S OBLIGATIONS AS A FEDERALLY DESIGNATED PATIENT SAFETY ORGANIZATION. THE INFORMATION, EXCLUDING ANY IDENTIFYING INFORMATION, WILL BE FORWARDED TO THE FDA AND DRUG OR DEVICE MANUFACTURER(S) IF PERTINENT TO HIE REPORT. PLEASE INDICATE BELOW WHETHER WE CAN INCLUDE YOUR NAME, ADDRESS, AND PHONE NUMBER WITH THE INFORMATION FORWARDED TO THE FDA. FDA: YES; NO. PLEASE FEEL FREE TO CONTACT ME IF YOU HAVE ANY FURTHER QUESTIONS. BEST REGARDS, (B)(6), PHARMD, MSHI, BCPS ISMP SAFE MEDICATION MANAGEMENT FELLOW. (B)(6); ISMP.ORG; (HTTPS://ISMP.ORG). CONFIDENTIALITY NOTICE: THIS E-MAIL MESSAGE, INCLUDING ANY ATTACHMENTS, IS FOR THE SOLE USE OF THE INTENDED RECIPIENT(S) AND MAY CONTAIN CONFIDENTIAL AND PRIVILEGED INFORMATION. ANY UNAUTHORIZED REVIEW, USE, DISCLOSURE OR DISTRIBUTION IS PROHIBITED. IF YOU ARE NOT THE INTENDED RECIPIENT, PLEASE CONTACT THE SENDER BY REPLY E-MAIL AND DESTROY ALL COPIES OF THE ORIGINAL MESSAGE. ORIGINAL MESSAGE FROM: ISMP INFO SENT: WEDNESDAY, JULY 26, 2023 11:40 AM TO: (B)(6) SUBJECT NEW CASE: MEDICATION SAFETY QUESTIONS OR CONCERN MEDISPAN DATA UPLOADS TO PMS A NEW CASE HAS BEEN CREATED. FIRST NAME: (B)(6), TOPIC: MEDICATION SAFETY QUESTIONS OR CONCERN SUBJECT: MEDISPAN DATA UPLOADS TO PMS NAME: EMAIL: (B)(6); PHONE: (B)(6) COMMENT: THIS HAS BOTHERED ME MOST OF MY 15 YEAR CAREER. OUR DRUG FILES (CURRENTLY COMPUTERRX) ARE UPDATED WITH DATA FROM MEDISPAN AND THE DRUG NAMES COME IN TRUNCATED FOR MANY DRUGS. I WAS TOLD BY COMPUTERRX THIS WAS NOTHING THEY CONTROL. SO WHEN A NEW DRUG IS ADDED TO OUR FILES, IT MAY BE NAMED 'METOPROL' OR 'LSOSORB' - THERE ARE QUITE A LOT OF THEM. I ACCEPT THAT SOME OLD PMS MAY HAVE LIMITED CHARACTER OPTIONS, BUT I THINK MOST MODERN ONES HAVE NO TROUBLE WITH THAT. EVEN SO, FORCING 98% TO HAVE THE WRONG DRUG NAME JUST IN ORDER TO ALLOW THE 2% TO AVOID AN UPDATE EXPENSE IS UNETHICAL. 1) THEY SEEM TO ME TO VIOLATE THE RX LABELING LAWS, 2) THEY BOTH RISK AND ACTUALLY HAVE CAUSED ERRORS WHEN TECHS ARE DOING INPUT. PARTICULARLY LESS EXPERIENCED TECHS. 3) THEY CAN CONFUSE PATIENTS SINCE THE PARTIAL NAME DOESN'T MATCH THEIR DISCHARGE SHEET OR MAY NOT MATCH A PREVIOUS RX. CONFUSION BREEDS ERRORS, BOTH AT PHARMACIES AND IN HOMES. CAN ANYONE LOOK INTO THIS AND SEE IF MEDISPAN (OR WHOEVER IS RESPONSIBLE) CAN CHANGE IT? HTTPS://ISMP.MY.SALESFORCE.COM/5006F00001SUKUQ; (HTTPS://ISMP.MY.SALESFORCE.COM/5006F00001SUKUQ) REF: (B)(4), (B)(6). SUBMISSION ID: (B)(6).