Achieving Medication Safety during Acute Kidney Injury: The Impact of Clinical Decision Support and Real-Time Pharmacy Surveillance

Abstract

The utilization of clinical decision support (CDS) is increasing among healthcare facilities that have implemented computerized physician order entry or electronic medical records. Formal prospective evaluation of CDS implementations rarely occurs, and misuse or flaws in system design are often not recognized or corrected. Through retrospective nephrologist adjudication of acute kidney injury (AKI) CDS alerts, we identified patient and knowledgebase factors that contributed to inappropriate, or false positive, alerts. We also estimated the rate of inappropriate provider responses, which occurred in the setting of both true and false positive alerts. We found that few alerts were determined to be inappropriate. Unintended adverse consequences, or inappropriate provider responses resulting from inappropriate alerts, were rare. Retrospective review often occurs too late to make critical corrections or initiate redesign efforts. We developed a real-time, web-based surveillance tool for nephrotoxic and renally cleared medications that integrates provider responses to CDS recommendations with relevant medication ordering, administration, and therapeutic monitoring data. The surveillance view displays all currently admitted, eligible patients and provides brief demographics with triggering order, laboratory, and CDS interactions to facilitate the identification of high-risk patient conditions, such as an imminent adverse drug event (ADE) or potential ADE (pADE). The patient detail view displays a detailed timeline of orders, order administrations, laboratory values, and CDS interactions for an individual patient and allows users to understand provider actions and patient condition changes occurring in conjunction with CDS interactions. We evaluated the surveillance tool with a randomized trial, where intervention patients were monitored on the surveillance tool daily by a clinical pharmacist and control patients received only existing CDS and standard of care. Despite interventions made by the study pharmacist from the surveillance tool, we found no significant change in the timeliness of provider modifications or discontinuations of targeted medications or occurrence of pADEs or ADEs. We concluded that clinical pharmacist surveillance of AKI-related medication alerts did not improve the timeliness or quality of provider responses or patient outcomes.