The support of medication reviews in hospitalised patients using a clinical decision support system

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Abstract

Objectives

First, to estimate the added value of a clinical decision support system (CDSS) in the performance of medication reviews in hospitalised elderly. Second, to identify the limitations of the current CDSS by analysing generated drug-related problems (DRPs).

Methods

Medication reviews were performed in patients admitted to the geriatric ward of the Zuyderland medical centre. Additionally, electronically available patient information was introduced into a CDSS. The DRP notifications generated by the CDSS were compared with those found in the medication review. The DRP notifications were analysed to learn how to improve the CDSS.

Results

A total of 223 DRP strategies were identified during the medication reviews. The CDSS generated 70 clinically relevant DRP notifications. Of these DRP notifications, 63 % (44) were also found during the medication reviews. The CDSS generated 10 % (26) new DRP notifications and conveyed 28 % (70) of all 249 clinically relevant DRPs that were found. Classification of the CDSS generated DRP notifications related to ‘medication error type’ revealed that ‘contraindications/interactions/side effects’ and ‘indication without medication’ were the main categories not identified during the manual medication review. The error types ‘medication without indication’, ‘double medication’, and ‘wrong medication’ were mostly not identified by the CDSS.

Conclusions

The CDSS used in this study is not yet sufficiently advanced to replace the manual medication review, though it does add value to the manual medication review. The strengths and weaknesses of the current CDSS can be determined according to the medication error types.

Related collections

Most cited references 28

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Effect of clinical decision-support systems: a systematic review.

Tiffani Bright, Anthony Wong, Ravi Dhurjati … (2012)

Despite increasing emphasis on the role of clinical decision-support systems (CDSSs) for improving care and reducing costs, evidence to support widespread use is lacking. To evaluate the effect of CDSSs on clinical outcomes, health care processes, workload and efficiency, patient satisfaction, cost, and provider use and implementation. MEDLINE, CINAHL, PsycINFO, and Web of Science through January 2011. Investigators independently screened reports to identify randomized trials published in English of electronic CDSSs that were implemented in clinical settings; used by providers to aid decision making at the point of care; and reported clinical, health care process, workload, relationship-centered, economic, or provider use outcomes. Investigators extracted data about study design, participant characteristics, interventions, outcomes, and quality. 148 randomized, controlled trials were included. A total of 128 (86%) assessed health care process measures, 29 (20%) assessed clinical outcomes, and 22 (15%) measured costs. Both commercially and locally developed CDSSs improved health care process measures related to performing preventive services (n= 25; odds ratio [OR], 1.42 [95% CI, 1.27 to 1.58]), ordering clinical studies (n= 20; OR, 1.72 [CI, 1.47 to 2.00]), and prescribing therapies (n= 46; OR, 1.57 [CI, 1.35 to 1.82]). Few studies measured potential unintended consequences or adverse effects. Studies were heterogeneous in interventions, populations, settings, and outcomes. Publication bias and selective reporting cannot be excluded. Both commercially and locally developed CDSSs are effective at improving health care process measures across diverse settings, but evidence for clinical, economic, workload, and efficiency outcomes remains sparse. This review expands knowledge in the field by demonstrating the benefits of CDSSs outside of experienced academic centers. Agency for Healthcare Research and Quality.

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Polypharmacy in elderly patients.

Emily Hajjar, Angela Cafiero, Joseph Hanlon (2007)

Polypharmacy (ie, the use of multiple medications and/or the administration of more medications than are clinically indicated, representing unnecessary drug use) is common among the elderly. The goal of this research was to provide a description of observational studies examining the epidemiology of polypharmacy and to review randomized controlled studies that have been published in the past 2 decades designed to reduce polypharmacy in older adults. Materials for this review were gathered from a search of the MEDLINE database (1986-June 2007) and International Pharmaceutical Abstracts (1986-June 2007) to identify articles in people aged >65 years. We used a combination of the following search terms: polypharmacy, multiple medications, polymedicine, elderly, geriatric, and aged. A manual search of the reference lists from identified articles and the authors' article files, book chapters, and recent reviews was conducted to identify additional articles. From these, the authors identified those studies that measured polypharmacy. The literature review found that polypharmacy continues to increase and is a known risk factor for important morbidity and mortality. There are few rigorously designed intervention studies that have been shown to reduce unnecessary polypharmacy in older adults. The literature review identified 5 articles, which are included here. All studies showed an improvement in polypharmacy. Many studies have found that various numbers of medications are associated with negative health outcomes, but more research is needed to further delineate the consequences associated with unnecessary drug use in elderly patients. Health care professionals should be aware of the risks and fully evaluate all medications at each patient visit to prevent polypharmacy from occurring.

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Overriding of drug safety alerts in computerized physician order entry.

Heleen van der Sijs, Jos Aarts, Arnold Vulto … (2005)

Many computerized physician order entry (CPOE) systems have integrated drug safety alerts. The authors reviewed the literature on physician response to drug safety alerts and interpreted the results using Reason's framework of accident causation. In total, 17 papers met the inclusion criteria. Drug safety alerts are overridden by clinicians in 49% to 96% of cases. Alert overriding may often be justified and adverse drug events due to overridden alerts are not always preventable. A distinction between appropriate and useful alerts should be made. The alerting system may contain error-producing conditions like low specificity, low sensitivity, unclear information content, unnecessary workflow disruptions, and unsafe and inefficient handling. These may result in active failures of the physician, like ignoring alerts, misinterpretation, and incorrect handling. Efforts to improve patient safety by increasing correct handling of drug safety alerts should focus on the error-producing conditions in software and organization. Studies on cognitive processes playing a role in overriding drug safety alerts are lacking.

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Author and article information

Contributors

Hugo A. J. M. de Wit: 0031(0)45-5766666 , h.dewit@zuyderland.nl

Kim P. G. M. Hurkens: ki.hurkens@zuyderland.nl

Carlota Mestres Gonzalvo: c.mestresgonzalvo@zuyderland.nl

Machiel Smid: m.smid@zuyderland.nl

Walther Sipers: w.sipers@zuyderland.nl

Bjorn Winkens: bjorn.winkens@maastrichtuniversity.nl

Wubbo J. Mulder: wj.mulder@mumc.nl

Rob Janknegt: r.janknegt@zuyderland.nl

Frans R. Verhey: f.verhey@maastrichtuniversity.nl

Paul-Hugo M. van der Kuy: h.vanderkuy@zuyderland.nl

Jos M. G. A. Schols: jos.schols@maastrichtuniversity.nl

Journal

Journal ID (nlm-ta): Springerplus

Journal ID (iso-abbrev): Springerplus

Title: SpringerPlus

Publisher: Springer International Publishing (Cham )

ISSN (Electronic): 2193-1801

Publication date (Electronic): 24 June 2016

Publication date PMC-release: 24 June 2016

Publication date Collection: 2016

Volume: 5

Issue: 1

Electronic Location Identifier: 871

Affiliations

[ ]Department of Clinical Pharmacy and Toxicology, Zuyderland Medical Centre, Henri Dunantstraat 5, 6419 PC Heerlen, The Netherlands

[ ]Department of Internal Medicine, Section of Geriatric Medicine, Zuyderland Medical Centre, Sittard-Geleen, The Netherlands

[ ]Department of Clinical Pharmacy and Toxicology, Zuyderland Medical Centre, Sittard-Geleen, The Netherlands

[ ]Department of Methodology and Statistics, CAPHRI-School for Public Health and Primary Care, Maastricht University, Maastricht, The Netherlands

[ ]Department of Internal Medicine, Maastricht University Medical Centre, Maastricht, The Netherlands

[ ]Department of Psychiatry and Neuropsychology, Alzheimer Centrum Limburg/School for Mental Health and Neurosciences, Maastricht University, Maastricht, The Netherlands

[ ]Department of General Practice and Department of Health Services Research, CAPHRI-School for Public Health and Primary Care, Maastricht University, Maastricht, The Netherlands

Article

Publisher ID: 2376

DOI: 10.1186/s40064-016-2376-1

PMC ID: 4920784

PubMed ID: 27386320

SO-VID: 172da5d3-6a28-4e9c-b255-801a735bda96

License:

Open AccessThis article is distributed under the terms of the Creative Commons Attribution 4.0 International License ( http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made.

History

Date received : 9 December 2015

Date accepted : 20 May 2016

Funding

Funded by: FundRef http://dx.doi.org/10.13039/501100001826, Netherlands Organisation for Health Research and Development;

Award ID: 113101001

Award Recipient : Paul-Hugo M. van der Kuy

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ScienceOpen disciplines: Uncategorized

Keywords: clinical decision support systems,medication errors,geriatrics

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ScienceOpen disciplines: Uncategorized

Keywords: clinical decision support systems, medication errors, geriatrics

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The support of medication reviews in hospitalised patients using a clinical decision support system

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Abstract

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Hogrefe Medicine

Most cited references 28

Effect of clinical decision-support systems: a systematic review.

Polypharmacy in elderly patients.

Overriding of drug safety alerts in computerized physician order entry.

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