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Course: Electronic Health Record Interoperability—Why Electronically Discontinued Medications Are Still Dispensed

CME Credits: 1.00

Released: 2021-08-30

A 69-year-old woman with a history of epilepsy presented to the emergency department (ED) for recurrent falls, gait instability, and emesis during the previous 3 months. A recent hospital admission had failed to uncover a clear cause of her falls, one of which led to an eye laceration and hand fracture that required an inpatient rehabilitation stay. Her seizures were historically well controlled while taking levetiracetam, although phenytoin was added after a seizure, which was later determined to be secondary to running out of levetiracetam. As a result, her neurologist discontinued phenytoin in the electronic health record (EHR) 6 months prior to her most recent admission and recommended treatment with levetiracetam only. The patient reported she was unaware of this change and had been taking both medications, as each continued to be dispensed by her pharmacy.


Educational Objective
To describe implications of electronic prescription programs used within electronic health records and pharmacy systems and the resulting risks of dispensing of discontinued medications.


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