Impact of a pharmacotherapy alerting system on medication errors

Area of Science:

• Health Informatics
• Clinical Pharmacy
• Patient Safety

Background:

• Medication errors during order verification pose a significant risk to patient safety in hospitals.
• Existing alerting systems often generate excessive alerts, leading to alert fatigue and reduced effectiveness.

Purpose of the Study:

• To evaluate a rules-based pharmacotherapy alerting system designed to identify and prevent improperly verified new medication orders.
• To assess the impact of the alerting system and a pharmacy response team on order-verification errors and subsequent interventions.

Main Methods:

• A retrospective pre-post cohort study was conducted at a 900-bed hospital.
• An alerting system was implemented, initially with broad alerts, then refined to focus on four specific medications (darbepoetin, filgrastim, fondaparinux, warfarin).
• A pharmacy response team provided near real-time feedback on alerts to order-verification pharmacists.

Main Results:

• A 36% decrease in order-verification alerts was observed post-implementation (p = 0.035).
• The average number of daily alerts decreased from 1.0 to 0.6.
• Pharmacy interventions in response to alerts averaged 10.2 minutes during the intervention phase.

Conclusions:

• The pharmacotherapy alerting system, coupled with an oversight response process, significantly reduced alert frequency.
• This integrated approach effectively facilitated the interception and prevention of potential adverse drug events at the order-verification stage.