ArticleBMJ health & care informatics2025
Enhancing medication safety with System Approach to Verifying Electronic Prescriptions (SAV E-Rx): pharmacists' review of product selection outcomes between prescribed and dispensed medications.
Article in BMJ health & care informatics, 2025. The graph could read no effect estimate from its abstract, so it casts no vote on the map. Cited by 2 papers.
What it found
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The trial behind it
Trials whose registry record cites this paper, or whose number appears in the abstract. A trial that started after this paper was published is citing it as background, not reporting it.
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Who cites it
2 citing papers in PubMed.
- Barriers to Electronic Prescription Circulation Under Employee Medical Insurance Outpatient Coordination: Evidence from a Pilot City in China.Risk management and healthcare policy · 2026Article
- The role of digital pharmaceutical governance in alleviating health inequality: a case study of the "Sanya Model" for centralized regional prescription review.Frontiers in public health · 2026Observational
Corrections and comments
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Authors and funding
7 authors.
Funding
Abstract
objectivesElectronic prescriptions (e-prescriptions) introduce drug product selection mismatches during pharmacy data entry. System Approach to Verifying Electronic Prescriptions (SAV E-Rx) detects and alerts pharmacy staff to clinically significant occurrences. This study evaluates outcomes of the identified mismatches.
methodsA retrospective analysis was conducted using 1 year of e-prescriptions and dispensing data from 14 community pharmacies across 9 US states. SAV E-Rx screened the data, and flagged mismatches were reviewed by pharmacists using the Common Formats for Event Reporting. Data were analysed using descriptive statistics, the Mann-Whitney U test and χ
resultsOf 1 250 804 records processed, 699 662 included sufficient data for comparison. Pharmacists classified 587 (88.7%) flagged records as intended mismatches and 75 (11.3%) as unintended. Intended mismatches involved ingredients (26.2%), strengths (53.7%) and dosage forms (47.4%), mainly due to prescriber-approved substitutions (62.4%). Unintended mismatches stemmed from ingredients (42.7%), strengths (36.0%) and dosage forms (54.7%) discrepancies, primarily reported as human error (82.7%) and labelling issues (76.0%). Future alerts were favoured for unintended mismatches (96.0%) compared with intended mismatches (56.7%) (p<0.001). DISCUSSION: While routine substitutions are a normal part of quality and timely care, unintended mismatches may pose clinical risks. These errors can arise from human factors and workflow challenges, including high prescription volumes and manual overrides. SAV E-Rx serves as an independent, automated safety net that flags mismatches, catching postdispensing errors that would otherwise go unnoticed.
conclusionsE-prescription errors remain a safety concern. Routine implementation of SAV E-Rx could enhance error detection and enable timely interventions.
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