A trial of automated decision support alerts for contraindicated medications using computerized physician order entry

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A Trial of Alerts designed to reduce Inpatient Administration of Medications contraindicated due to Renal Insufficiency

Secondary to the high use of multiple medications hospitalized patients are at risk for adverse drug events (ADEs). ADEs result in increase in cost of care as well as increased morbidity and mortality. Patients with renal insufficiency are at increased risk of ADEs from medication administration. The University of Illinois Hospital and Medical Center trialed a real-time CDS (clinical decision support) alert to reduce the incidence of medication administration contraindicated due to renal insufficiency. After a minimum safe creatinine clearance was established for each inpatient formulary medication, a “pop-up” alert recommending cancellation was developed for a medication order initiated for a patient whose estimated creatinine clearance was less than the safe creatinine clearance for the medication.

To further analyze the efficacy of the alert, the study reviewed the impact of patient demographics, degree of renal dysfunction, and the duration of housestaff training. After 14 months of the study, the 323 alerts were generated and the likelihood of receiving at least one dose of a contraindicated medication was reduced from 89% to 47% (p<0.0001). This 42% absolute reduction was seen mostly in cancellation of the order and predominately in housestaff clinicians (70% of the distribution). Interestingly, patient female gender (38% vs. 58%; p=0.02) and improving renal function were associated with lower alert compliance rates. In summary, the 226 alerts received by housestaff resulted in only a 42% compliance rate.

Comment: This study showed how a “real-time” pop-up CDS alert could reduce the number of medication errors and highlighted the ongoing issue of noncompliance with alerts. Furthermore, while more experienced housestaff were more likely to follow the alerts, it would be interesting to further elucidate the rationale for ignoring and/or overriding the alerts.