List of 39 Warning Messages Targeting Prescribing Decisions Designed to Prevent Adverse Drug Events in Long-Term Care

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From: Rochon PA, Field TS, Bates DW, Lee M, Gavendo L, Erramuspe-Mainard J, Judge J, Gurwitz JH. Computerized physician order entry with clinical decision support in the long-term care setting: insights from the Baycrest Centre for Geriatric Care. J Am Geriatr Soc. 2005 Oct;53(10):1780-9. Accessed 2-10-2009
Warning Messages Targeting Prescribing Decisions Designed to Prevent Adverse Drug Events in Long-Term Care


INR=international normalized ratio; NSAIDs=nonsteroidal antiinflammatory drugs; ACE inhibitors=angiotensin-converting enzyme inhibitors; BUN=blood urea nitrogen; SSRIs=selective serotonin reuptake inhibitors; CNS=central nervous system; TSH=thyroid-stimulating hormone.
Scenario DescriptionWarning/Message
Warfarin order in setting of most-recent INR of >3 WARNING—BLEEDING RISK -- INR is ——. Current INR is high. Reduce WARFARIN dose and/or monitor closely.
Warfarin interaction with trimethoprim/sulfamethoxazole, amoxicillin/clavulanate WARNING—BLEEDING RISK -- This drug can interact profoundly with WARFARIN. Consider an alternative antibiotic or monitor very closely. Repeat the INR in 3 days and consider reducing warfarin dose.
Warfarin-antibiotic interaction WARNING—BLEEDING RISK -- This drug interacts with WARFARIN. Repeat the INR in 3 days. Consider reducing warfarin dose.
Warfarin-nonantibiotic interaction (e.g., amiodarone) WARNING—BLEEDING RISK -- This drug interacts with WARFARIN. Monitor very closely. Repeat the INR in 3 days.
Warfarin-antiplatelet drug or NSAID interaction WARNING—BLEEDING RISK -- The use of WARFARIN with NSAIDs and/or ANTIPLATELET AGENTS increases bleeding risk. Reevaluate need for concomitant therapy.
Warfarin-nonantibiotic interaction (e.g., amiodarone) WARNING—BLEEDING RISK -- This drug interacts with WARFARIN. Monitor very closely. Repeat the INR in 3 days.
Antiplatelet drug—NSAID interaction WARNING—BLEEDING RISK -- The use of ANTIPLATELET AGENTS with NSAIDs increases bleeding risk. Evaluate need for concomitant therapy.
Any use of NSAIDs, ACE inhibitors, diuretics in resident with BUN and/or creatinine above certain threshold level WARNING—RENAL INSUFFICIENCY RISK -- Current BUN=——, Creatinine=——. Worsening renal insufficiency can result from ACE inhibitors, angiotensin receptor blockers (e.g., losartan), diuretics, and NSAIDs. Evaluate medication regimen and monitor BUN and CREATININE closely.
Any drug therapy that can increase potassium level (ACE inhibitors, potassium-sparing diuretics, potassium supplements, NSAIDs) WARNING—HYPERKALEMIA RISK -- Most recent POTASSIUM is —. HYPERKALEMIA can result from therapy with any of the following: ACE inhibitors, angiotensin receptor blockers (e.g., losartan), potassium-sparing diuretics, NSAIDs, and mineralocorticoids. Reevaluate medication regimen and monitor POTASSIUM level closely.
Any new prescription for thiazide or loop diuretic therapy WARNING—HYPOKALEMIA RISK -- Hypokalemia can result from use of thiazide and loop diuretics. Check POTASSIUM level in 7–10 days and continue monitoring.
Anticholinergic medications (e.g., nortriptyline) WARNING—RISK OF ANTICHOLINERGIC EFFECTS -- This drug poses a high risk of dry mouth, constipation, urinary retention, and delirium. Use the lowest feasible dose. Monitor closely for these effects.
Oxybutynin and tolterodine WARNING—RISK OF URINARY RETENTION -- Order a bladder scan 7 days after initiation of therapy or any change in dose and monitor.
Opioid therapy WARNING—CONSTIPATION RISK -- Opiates can cause constipation. Monitor closely and prevent constipation. Choose a laxative other than docusate sodium. Order a scheduled dose.
Concomitant use of prednisone or thiazide diuretic and hypoglycemic agent WARNING—RISK OF HYPERGLYCEMIA -- Oral corticosteroids and hydrochlorothiazide can worsen glucose control. Monitor finger sticks carefully.
Digoxin therapy WARNING—RISK OF DRUG TOXICITY -- Digoxin doses should rarely exceed 0.125 mg per day because of reduced renal clearance in elderly. Recheck digoxin level with any change in dose.
Dose suggestions for benzodiazepines, NSAIDs, and antipsychotics WARNING—DOSE RECOMMENDATION -- The recommended initial dose of this drug is — mg. High doses increase risk of side effects.
Long-acting benzodiazepines WARNING—RISK OF SEDATING EFFECTS -- Diazepam, clonazepam, chlordiazepoxide, nitrazepam, and bromazepam have a very long half-life, increasing risk for CNS side effects. Consider substituting a short-acting benzodiazepine such as oxazepam if appropriate.
Muscle relaxants and antispasmodic drugs WARNING—RISK OF SEDATING EFFECTS -- Most muscle relaxants and antispasmodics are poorly tolerated, leading to anticholinergic effects and sedation. Try to avoid their use.
Low TSH in setting of thyroid replacement therapy WARNING—OVERTREATMENT -- Current TSH: ——. A low TSH level in the setting of thyroid replacement therapy may reflect toxicity (even when other thyroid function tests are normal). Reduce dose of thyroid replacement therapy. Recheck TSH in 6 weeks.
Phenytoin initiation WARNING—MONITOR DRUG LEVEL -- Most recent phenytoin level: ———. Order phenytoin level 5–7 days after initiation of therapy or any change in dose.
Serious drug-drug interaction with amiodarone (e.g., interaction with quinidine) SERIOUS DRUG-DRUG INTERACTION -- Amiodarone can increase the levels of many drugs. Check for interactions. Monitor closely.
Serious drug-drug interaction with phenytoin (e.g., interaction with trimethoprim/sulfamethoxazole) SERIOUS DRUG-DRUG INTERACTION -- This combination can affect phenytoin levels. Monitor closely.
Serious drug-drug interaction with lithium SERIOUS DRUG-DRUG INTERACTION -- In general, the concomitant use of NSAIDs, diuretics, or ACE inhibitors with lithium should be avoided because of toxicity risk.
Serious drug-drug interaction with selegiline (e.g., interaction with SSRIs) SERIOUS DRUG-DRUG INTERACTION -- This combination can lead to a serotonin-like syndrome, a potentially life-threatening event.
Serious drug-drug interaction with digoxin (e.g., interaction with verapamil) SERIOUS DRUG-DRUG INTERACTION -- This combination can lead to digoxin toxicity. Monitor digoxin level closely.
Serious drug-drug interaction with monoamine oxidase inhibitors (e.g., interaction with SSRIs) SERIOUS DRUG-DRUG INTERACTION -- This combination can lead to serotonin syndrome, a potentially life-threatening event.
Serious drug-drug interaction with theophylline (e.g., interaction with quinolones) SERIOUS DRUG-DRUG INTERACTION -- This combination can lead to theophylline toxicity. Monitor theophylline level closely.
Serious drug interaction between phenobarbital and warfarin SERIOUS DRUG-DRUG INTERACTION -- Phenobarbital can reduce the effect of warfarin. Monitor INR closely.
Serious drug-drug interaction with bromocriptine (e.g., interaction with pseudoephedrine) SERIOUS DRUG-DRUG INTERACTION -- This combination can lead to severe hypertension and seizures.
Serious drug interaction between allopurinol and thiazide diuretics SERIOUS DRUG-DRUG INTERACTION -- This combination can lead to an increased risk of hypersensitivity reactions to allopurinol.
Serious drug interaction between clozapine and risperidone SERIOUS DRUG-DRUG INTERACTION -- This combination may increase the risk of toxicity from risperidone. Monitor closely.
Serious drug-drug interaction with clozapine (e.g., interaction with citalopram) SERIOUS DRUG-DRUG INTERACTION -- This combination may increase the risk of toxicity from clozapine. Monitor closely.
Serious drug-drug interaction with tramadol (e.g., interaction with paroxetine) SERIOUS DRUG-DRUG INTERACTION -- Avoid this combination; may increase the risk of seizures.
Serious drug interaction between SSRIs and tricyclic antidepressants SERIOUS DRUG-DRUG INTERACTION -- Use this combination with extreme caution. This may cause toxic tricyclic levels.
Serious drug-drug interaction with methotrexate (e.g., interaction with phenytoin) SERIOUS DRUG-DRUG INTERACTION -- This combination can increase the risk of methotrexate toxicity.
Serious drug interaction between quinidine and itraconazole SERIOUS DRUG-DRUG INTERACTION -- This combination can increase the risk of quinidine toxicity and should be avoided.
Serious drug-drug interaction which which QT interval prolongation risk (e.g., macrolides and phenothiazines) SERIOUS DRUG-DRUG INTERACTION: QT prolongation risk. These agents may produce QT interval prolongation and should not be used together.