Category: Quality Assurance/Quality Improvement
Keywords: discharge prescriptions, transitions of care, pharmacy callbacks (PubMed Search)
Posted: 2/22/2026 by Lena Carleton, MD
(Updated: 2/23/2026)
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Key Takeaway: Most emergency department prescription callbacks for clarification are preventable. The most frequently identified causes include unclear directions for use, incorrect medication or dose, allergy or adverse reaction concerns, and duplicate prescriptions. A quick double-check before you hit “send” can save you (and the pharmacist) a callback later.
Most patients seen in the emergency department (ED) are discharged with at least one prescription. However, errors in ED discharge prescriptions are not uncommon (one study reported an error rate of 13.4%) and can contribute to delays in care, medication nonadherence, and return ED visits, among other adverse events.
In this retrospective study, the authors analyzed a quality improvement database of pharmacy clarification requests to categorize and quantify the reasons pharmacies contact ED clinicians. The study was conducted at an academic emergency department in Arizona.
From October 2015 to February 2024, 2,714 clarification requests were identified. Of these, 63.4% were considered potentially preventable. The most frequently identified causes were unclear directions for use (33.1%), medication clarification (12.3%), dose clarification (11.5%), allergy or adverse reaction concerns (5.0%), and duplicate prescriptions (1.5%).
Nonpreventable clarifications accounted for 36.6% of requests and were related to insurance issues (14.6%), medication availability (14.0%), patient factors such as delayed presentation or lost prescriptions (4.8%), and requests to transfer prescriptions to another pharmacy (3.2%).
Notably, pediatric patients were nearly three times more likely than adults aged 18–64 to require dose clarification, likely reflecting the complexity of weight-based dosing. The authors suggest including patient weight on prescriptions when weight-based dosing is used to reduce pharmacy callbacks.
Key Takeaway: Most emergency department prescription callbacks for clarification are preventable. The most frequently identified causes include unclear directions for use, incorrect medication or dose, allergy or adverse reaction concerns, and duplicate prescriptions. A quick double-check before you hit “send” can save you (and the pharmacist) a callback later.
Elias-Campa D, Edwards CJ, Shirzai FM, Ng V. Identifying Preventable and Nonpreventable Prescription Callbacks for Clarification at an Academic Medical Center Emergency Department From 2015 to 2024. J Emerg Med. 2025 Nov;78:371-378. doi: 10.1016/j.jemermed.2025.03.023. Epub 2025 Apr 2. PMID: 41027291.
Kelly A. Murray, April Belanger, Lauren T. Devine, Aaron Lane & Michelle E. Condren (2017) Emergency Department Discharge Prescription Errors in an Academic Medical Center, Baylor University Medical Center Proceedings, 30:2, 143-146, DOI: 10.1080/08998280.2017.11929562
