From Routine Call to Critical Catch: How Medication Management Keeps Patients Safer

In healthcare, some of the most significant patient safety interventions begin with routine checks. What started as a standard follow-up call about an unfilled prescription turned into a critical catch that prevented a potentially dangerous medication interaction. This case highlights the vital importance of comprehensive medication review and the often-invisible safety net that pharmacists provide in our healthcare system.

When our clinical pharmacy team identified potentially harmful duplicate prescriptions during what seemed like a routine prescription refill inquiry, their quick action and thorough follow-up demonstrated how vigilant medication management can protect patient safety. The situation revealed a common but dangerous scenario in modern healthcare: multiple providers prescribing similar medications without full awareness of a patient's complete medication profile.

The Challenge

A member faced a critical medication safety issue:

- Two different medications from the same drug class (Entresto and Losartan)

- Prescriptions written by separate physicians

- Lack of coordination between providers

- Potential for dangerous drug interaction

- Complicated by current hospital admission

Taking Action

Our ActualMeds pharmacist took comprehensive steps to address the situation:

1. Initiated a follow-up call with the pharmacy regarding an unfilled prescription
2. Discovered the duplicate therapy during medication review
3. Contacted both prescribing physicians to alert them of the overlapping prescriptions
4. Identified that the member was currently hospitalized
5. Coordinated with the pharmacy to pause all medication dispensing until hospital discharge

The Impact

Through this coordinated effort, we prevented a potentially dangerous drug interaction and ensured proper medication management during a vulnerable transition of care.

The pharmacist's intervention allowed for:

- Discontinuation of contraindicated duplicate therapy

- Clear communication between all healthcare providers

- Safe medication management during hospitalization

- Appropriate medication reconciliation upon discharge

- Continuation of only the most suitable medication moving forward

This success story demonstrates how proactive medication monitoring and care coordination can prevent adverse drug events. By following through on a routine prescription inquiry and taking immediate action when issues were discovered, our pharmacy team helped ensure this member's safety and well-being.

Is your team able to achieve this type of success? If not, start improving your members' medication safety today. Contact us to learn more.