Pet Medications- A Tail of Caution.

Case Report Pet Medications: A Tail of Caution Tammy T. Nguyen, PharmD, BCPS 1 , Craig F. Kirkwood, PharmD 2,3 , Denise Reilly, PharmD, CPHIMS 4 , Danyae Lee, PharmD, BCPS 5 , and Christy Coggin, PharmD 6 Abstract Purpose: A case report of pet medications appearing along with the patient’s medications (pet owner) in the external medication history list of the electronic medical record (EMR). Case Presentation: A 67-year-old female presented to the emergency department for altered mental status. A medication history was performed by the pharmacist in an attempt to identify possible etiologies of the patient’s clinical status. An external prescription refill report from the EMR included 2 medications that could not be confirmed by the family as the patient’s: phenobarbital 50 mg twice daily and zonisamide 200 mg every 12 hours. The patient’s pharmacy identified that the prescriptions were pet medications registered under the patient’s name and date of birth for the state’s prescription monitoring program. Conclusion: A lack of standardization between pet identifiers in community pharmacy databases and state Board of Pharmacy regulations for prescription monitoring programs, has led to the association of pet medications with their human owners in the EMR. Patient medication histories should always be verified and validated utilizing patient/patient family interviews and prescription refill histories. Utilization of pharmacists to identify and scrutinize incon- sistencies can reduce medication errors that could occur during medication history or reconciliation. Keywords medication safety, transitions of care Background Medication errors are a leading cause of avoidable harm, and pose a significant threat to patient safety as they have the potential to result in adverse drug events (ADEs). According to the World Health Organization (WHO), approximately 67 % of patients’ admission medication histories have one or more errors. 1 A patient’s medication list can incur further discrepan- cies as they transition through care, and unfortunately unin- tended errors can range between 30 % -70 % . 2 Medication reconciliation is the formal process of creating an accurate list of all medications a patient is taking, including drug name, dosage, route of intake, frequency and adherence, and ensuring that this information is communicated consis- tently across transitions of care. 3 The Joint Commission (TJC) has identified medication reconciliation as an important safety issue in their 2020 National Patient Safety Goals. 4 The WHO’s third Global Patient Safety Challenge: Medication Without Harm focused on medication reconciliation during transitions of care with the goal to reduce severe, avoidable harm related to medications by 50 % over 5 years. 5 Pharmacists’ expertise enables them to effectively and efficiently collect medication histories and perform medication reconciliation, therefore reducing possible preventable ADEs and ensuring patient safety. 6 Tools often utilized to ensure accurate medication his- tories include patient/family interviews, medication bottles, pharmacy refill history, medication administration records, and prescription monitoring program (PMP) records. The obtainment of accurate medication histories in Virginia became more challenging on July 1, 2018 when the state’s legislative action SB 226 required pharmacies to utilize the pet’s human owner’s name and date of birth when dispensing controlled substance prescriptions >7 days for the pet. 7 The utilization of the human owner’s information, instead of the pet’s, allows controlled substances to be tracked through the state’s PMP. Unfortunately, this has resulted in the merging 1 Emergency Medicine, Department of Pharmacy Services, Virginia Common- wealth University Health System, Richmond, VA, USA 2 Pharmacotherapy & Outcomes Science, Department of Pharmacy Services, Virginia Commonwealth University Health System, Richmond, VA, USA 3 Virginia Commonwealth University School of Pharmacy, Richmond, VA, USA 4 Pharmacy Informatics, Department of Pharmacy Services, Virginia Com- monwealth University Health System, Richmond, VA, USA 5 Medication Safety, Department of Pharmacy Services, Virginia Common- wealth University Health System, Richmond, VA, USA 6 Department of Pharmacy Services, Virginia Commonwealth University Health System, Richmond, VA, USA Corresponding Author: Tammy T. Nguyen, Virginia Commonwealth University Health System, 1250 E Marshall St, PO Box 980042, Richmond, VA 23298, USA. Email: tammy.nguyen@vcuhealth.org Journal of Pharmacy Practice ª The Author(s) 2020 Article reuse guidelines: sagepub.com/journals-permissions DOI: 10.1177/0897190020966149 journals.sagepub.com/home/jpp 2022, Vol. 35(2) 317–321

318 Journal of Pharmacy Practice 35(2) of the pet and the human owner’s medications in the human’s electronic medical record (EMR), with no standard designation of what is a human medication versus a pet medication across healthcare entities. We present such a case where high risk anti- epileptic pet medications were identified in the human pet owner’s medication profile. Case Report A 67-year-old 75 kg Caucasian female with a past medial history of depression, Parkinson’s disease, diabetes, and hyper- tension, presented to the emergency department (ED) for altered mental status. The patient was hyperthermic with a temperature of 38.4 degrees Celsius, tachycardic with a heart rate of 140 beats/minute, and hypertensive with systolic blood pressure in the 220’s mm Hg. All labs were within normal limits and a toxicological screen (acetone, ethanol, isopropa- nol, methanol, barbiturates, benzodiazepines, cocaine, opiates, acetaminophen, and salicylates) was negative. While being assessed in the ED, the patient experienced a seizure and her Glasgow Coma Score (GCS), a measure of consciousness, rapidly deteriorated from a 14 (almost fully responsive) to a 3 (unconscious). Computed tomography of the head and abdo- men was negative for hemorrhage. At this time, the emergency medicine clinical pharmacist was consulted regarding concerns for medication withdrawal, therapeutic misadventure, or pos- sible intentional overdose. A medication history was completed by interviewing the patient’s family members at the bedside and reviewing medication bottles. An external prescription refill report (EPRR) was utilized to confirm the information provided. This report provides limited information on medica- tion name, dose, route, instructions, refill history, dispensing pharmacy, and prescriber based and is reported in the EMR (Cerner). It was identified by the clinical pharmacist that the patient may have missed doses of her carbidopa-levodopa, contributing to possible neuroleptic malignant syndrome. However, the patient’s medication history identified 2 medica- tions that could not be confirmed by the family: phenobarbital 50 mg by mouth twice daily and zonisamide 200 mg by mouth every 12 hours (Figure 1). This was concerning as the ED differential for the patient’s alteration in mental status included barbiturate withdrawal and status epilepticus. Although the patient seized in the ED, the family adamantly denied that the patient had a seizure history. The patient’s daughter, however, Figure 1. External prescription refill report.

320 Journal of Pharmacy Practice 35(2) differentiate between pet and human medications. Each com- munity pharmacy, however, has proprietary software applica- tions that may not have this flag set for various reasons: user omission, nonhuman flag is not aliased with the animal flag, or the nonhuman flag is not transmitted or honored. Therefore, when the EPRR is utilized in the clinical setting to identify a patient’s medication history, the receiving EMR may not iden- tify a pet medication in the owner’s external medication history. Without a standard process of entering pet medications in these software systems, profiles of owners and pets can be merged in the EMR, leading to significant harm if pet prescrip- tions are administered to the owner. High risk human medica- tions that are often prescribed and dispensed to pets include antibiotics, opioids, anti-epileptics, antidepressants, antipsy- chotics, sedatives, insulin, thyroid medications (e.g. levothyr- oxine, methimazole), and cardiac medications (e.g., atenolol, amlodipine, digoxin). 15 The addition and administration of any of these pet medications to their human owner’s medication profile due to an incorrect history or reconciliation could have deadly consequences. For some medications (e.g., levothyrox- ine) the canine dose may be ten-fold the human dose, which increases the probability of a fatal medication error. If the pharmacist had not identified the error in this patient case, the incorrect reconciliation of phenobarbital and zonisamide could have contributed to significant clinical sequela if they were administered including excessive central nervous system and respiratory depression, psychiatric symptoms, metabolic acido- sis, and hypersensitivity reactions. Our case is not the only report of a pet’s medications appear- ing in the owner’s EMR. The Institute for Safe Medication Practices (ISMP) reported a similar case in August 2019, days after our event. 16 The ISMP case occurred during a clinic med- ication reconciliation in which an external prescription report from the EMR (Epic) identified enalapril in the patient’s pro- file, but upon patient interview, it was identified that the ena- lapril was for the patient’s dog. Without the patient interview, this medication error would not have been recognized. Just prior to the publication of the article, another case was identi- fied by an internal medicine clinical pharmacist at our health system. A prescription for extended release oxycodone 120 mg by mouth every 8 hours appeared in a patient’s EPRR during a clinical pharmacist’s medication history review. The pharma- cist confirmed with the patient that this prescription was for his dog that had recently passed away. Unlike the phenobarbital in our case, the oxycodone was not flagged as a pet medication in the EPRR or state PMP, because the community pharmacy had put the pet designation in the “general notes” section of the prescription. These notes do not transfer in Surescripts to the EPRR and it is unclear if this mistake would have been caught without pharmacy involvement. This is another example of where administration of the extended release oxycodone could have resulted in a poor outcome for an opioid naı¨ve patient or possibly incorrectly identify him as being overprescribed opioids, when this was not the case. A 2015 survey in America’s Pharmacist identified signifi- cant variation in how states handle pet prescriptions. 17 As the commercial market for pet medication increases in community pharmacies and states modify regulations in response to an FDA warning of pet owners using their animals’ opioids, 18 a national standard is needed to establish a consistent process for dispensing and tracking pet prescriptions without inadvertently risking the health of their human owners. The nonhuman flag should be compatible and required in all prescription software programs. Boards of Pharmacy in each state should be aware that linking pet medications under the owner’s name and date of birth introduces the risk of pet medications being confused with their pet owner medications and require action to mitigate such risk such as mandating consistent, clear identification of all pet medications. This is an important issue that all health- care providers should be aware of when utilizing an EPRR to document or complete medication reconciliation in all health- care settings. In the 2 cases identified at our health system, clinical pharmacists participating in the medication reconcilia- tion process helped identify and address these errors. The incorporation of pharmacists and pharmacy technicians in the medication history and reconciliation process can decrease this risk. Conclusion A lack of standardization between pet identifiers required to create pet profiles in community pharmacy databases and state Board of Pharmacy regulations for PMPs has led to the asso- ciation of pets’ medications with their owners in the EMR. Patient medication lists should always be verified and validated utilizing a patient or patient family interviews and prescription refill histories. Utilization of pharmacists to identify and scru- tinize inconsistencies can reduce medication errors that could occur during the medication history/reconciliation process. Authors’ Note Manuscript prepared and assembled from August 2019 to April 2020 at Virginia Commonwealth University Health System in Richmond, VA, USA. Declaration of Conflicting Interests The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article. Funding The author(s) received no financial support for the research, author- ship, and/or publication of this article. ORCID iDs Tammy T. Nguyen, PharmD, BCPS https://orcid.org/0000-0003-3 546-0309 Denise Reilly, PharmD, CPHIMS https://orcid.org/0000-0001- 8809-570X

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