Abstract: This case report describes a safety event in which a widely-available EHR-embedded tool to query a prescription monitoring program (PMP) produced variable, discrepant results for the same patient. Thus creating risk that providers could make prescribing decisions with incomplete historical information, with potential for patient harm. After investigation, the vendor agreed to make a change impacting customers nationwide. There is need for better alignment of state PMP access policies to facilitate patient safety.

Describe the new knowledge and additional skills the participant will gain after attending your presentation.: The participant will appreciate the need to advocate for Prescription Monitoring Program access alignment across states, seek more clinical informatics oversight of EHR integration technologies, and recognize the ongoing importance of safety event reporting and investigations.


Joel Betesh (Presenter)
University of Pensylvania

Amy Schettino, University of Pennsylvania
Jenean Lane, University of Pennsylvania
John McGreevey, University of Pennsylvania