[As of 11:15 a.m. June 19]
Following is an advisory from Surescripts:
Date: June 18, 2018
Title: Notification of Potential Patient Safety Issue (PPSI) – Missing leading zero (aka, “Naked decimal”) in some Medication History response messages
Details: Surescripts recently determined that some Medication History response messages provided by certain pharmacy benefit managers (PBMs) and pharmacies may be missing leading zeroes in front of decimals in the Drug Description or Drug Strength field which could result in misinterpretation.
For example, instead of:
<DrugDescription>ANAGRELIDE HYDROCHLORIDE 0.5 MG CAPS</DrugDescription>,
it is transmitted as:
<DrugDescription>ANAGRELIDE HYDROCHLORIDE .5 MG CAPS</DrugDescription>.
As noted in our Medication History for Ambulatory Implementation Guide 10.6 (for PBMs) and Medication History Load for Pharmacies Implementation Guide v6.2, and supported by specific recommendations from the Institute for Safe Medication Practices (ISMP) and the Joint Commission, Medication History responses should always include a leading zero in front of a decimal for values less than 1 and greater than 0.
Surescripts conducted an analysis of sample data in 2018 and determined this issue is occurring in the Drug Description field of approximately 1.45% of Medication History response messages. This issue may also be occurring in the following fields:
- Directions
- Quantity
- DrugCoded
- Strength
- Diagnosis Code
There have been no reported cases of patient harm due to this issue, although due to the risk of an end-user not seeing a decimal point, and the potential for inaccurate doses to be transmitted as a result, this issue represents a Potential Patient Safety Issue (PPSI).
Surescripts is working with the data sources involved to resolve the issue as quickly as possible. We will provide an update on the fix as soon as it is available.
Meantime, please direct questions to x4400, Option 1.