Validity of a clinical decision rule based alert system for drug dose adjustment in patients with renal failure intended to improve pharmacists' analysis of medication orders in hospitals

TL;DR

This study evaluates a clinical decision alert system for renal drug dosing, finding it detects more errors and fewer false negatives than pharmacists, thus potentially enhancing medication safety in hospitals.

Contribution

It introduces and validates an alert system that complements pharmacists by improving detection of drug dose errors in renal failure patients.

Findings

Alert system fired in 8.41% of cases

Alert system detected more appropriate alerts than pharmacists

Pharmacists missed many errors due to understaffing

Abstract

Objective: The main objective of this study was to assess the diagnostic performances of an alert system integrated into the CPOE/EMR system for renally cleared drug dosing control. The generated alerts were compared with the daily routine practice of pharmacists as part of the analysis of medication orders. Materials and Methods: The pharmacists performed their analysis of medication orders as usual and were not aware of the alert system interventions that were not displayed for the purpose of the study neither to the physician nor to the pharmacist but kept with associate recommendations in a log file. A senior pharmacist analyzed the results of medication order analysis with and without the alert system. The unit of analysis was the drug prescription line. The primary study endpoints were the detection of drug-dose prescription errors and inter-rater reliability between the alert system and the pharmacists in the detection of drug dose error. Results: The alert system fired alerts in 8.41% (421/5006) of cases: 5.65% (283/5006) exceeds max daily dose alerts and 2.76% (138/5006) under dose alerts. The alert system and the pharmacists showed a relatively poor concordance: 0.106 (CI 95% [0.068, 0.144]). According to the senior pharmacist review, the alert system fired more appropriate alerts than pharmacists, and made fewer errors than pharmacists in analyzing drug dose prescriptions: 143 for the alert system and 261 for the pharmacists. Unlike the alert system, most diagnostic errors made by the pharmacists were false negatives. The pharmacists were not able to analyze a significant number (2097; 25.42%) of drug prescription lines because understaffing. Conclusion: This study strongly suggests that an alert system would be complementary to the pharmacists activity and contribute to drug prescription safety.