Adopting real-time surveillance dashboards as a component of an enterprisewide medication safety strategy.

BACKGROUND: High-alert medications are frequently responsible for adverse drug events and present significant hazards to inpatients, despite technical improvements in the way they are ordered, dispensed, and administered. METHODS: A real-time surveillance application was designed and implemented to enable pharmacy review of high-alert medication orders to complement existing computerized provider order entry and integrated clinical decision support systems in a tertiary care hospital. The surveillance tool integrated real-time data from multiple clinical systems and applied logical criteria to highlight potentially high-risk scenarios. Use of the surveillance system for adult inpatients was analyzed for warfarin, heparin and enoxaparin, and aminoglycoside antibiotics. RESULTS: Among 28,929 hospitalizations during the study period, patients eligible to appear on a dashboard included 2224 exposed to warfarin, 8383 to heparin or enoxaparin, and 893 to aminoglycosides. Clinical pharmacists reviewed the warfarin and aminoglycoside dashboards during 100% of the days in the study period-and the heparinlenoxaparin dashboard during 71% of the days. Displayed alert conditions ranged from common events, such as 55% of patients receiving aminoglycosides were missing a baseline creatinine, to rare events, such as 0.1% of patients exposed to heparin were given a bolus greater than 10,000 units. On the basis of interpharmacist communication and electronic medical record notes recorded within the dashboards, interventions to prevent further patient harm were frequent. CONCLUSIONS: Even in an environment with sophisticated computerized provider order entry and clinical decision support systems, real-time pharmacy surveillance of high-alert medications provides an important platform for intercepting medication errors and optimizing therapy.

Effects of clinical decision support on initial dosing and monitoring of tobramycin and amikacin.

PURPOSE: The impact of clinical decision support (CDS) on initial doses and intervals and pharmacokinetic outcomes of amikacin and tobramycin therapy was evaluated. METHODS: A complex CDS advisor to provide guidance on initial dosing and monitoring of aminoglycoside orders, using both traditional-dosing and extended-interval-dosing strategies, was integrated into a computerized prescriber-order-entry (CPOE) system and compared with a control group whose aminoglycoside orders were closely monitored by pharmacists. The primary outcome measured was an initial dose within 10% of a dose calculated to be adherent to published dose guidelines. Secondary outcomes included a guideline-adherent interval, trough and peak concentrations in goal range, and rate of nephrotoxicity. RESULTS: Of 216 patients studied, 97 were prescribed amikacin and 119 were prescribed tobramycin. The number of orders with initial doses consistent with reference standards increased from 40% in the preadvisor group to 80% in the postadvisor group (p < 0.001). Selection of the correct initial interval based on renal function increased from 63% to 87% (p < 0.001). The changes in the initial dosing and interval resulted in an increase of trough concentrations at goal (59% in the preadvisor group versus 89% in the postadvisor group, p = 0.0004). There was no significant difference in peak concentrations in the goal range or rate of nephrotoxicity. CONCLUSION: An advisor for aminoglycoside dosing and monitoring integrated into a CPOE system significantly improved selection of initial doses and intervals and resulted in an improvement in the rate of trough serum drug concentrations at goal compared with standard provider dosing.

Improving aminoglycoside dosing through computerized clinical decision support and pharmacy therapeutic monitoring systems.

Dosing errors and inadequate laboratory monitoring of aminoglycosides may lead to significant adverse drug events. Correctly prescribing aminoglycosides requires familiarity with multiple mathematically complicated dosing and laboratory monitoring protocols. We developed a clinical decision support system for ordering aminoglycosides which is integrated into a computerized provider order entry system. To complement the ordering tool, we implemented a real-time tracking application to allow the pharmacist-staffed therapeutic drug monitoring service to follow patients prescribed aminoglycosides.