ALERTS TO REDUCE MEDICATION ERRORS IN

1
ALERTS TO REDUCE MEDICATION ERRORS IN
IN-PATIENTS WITH RENAL INSUFFICIENCY
W. Galanter1, L. Canonge2, R. Didomenico3, K.
Kopec3, A. Looi2, J. Paek3, A. Polikaitis4, M.
Thambi3 and J. Welch2 1 Department of Medicine
2 Information Technology Services 3 Department
of Pharmacy Practice, University of Illinois at
Chicago, Chicago, Illinois 4 Cerner Corporation,
Kansas City, Missouri
ALERT DEVELOPMENT
INTRODUCTION
CONCLUSIONS
Determination of which drugs involved and in what
manner
Adverse drug events (ADE) contribute
significantly to adverse events associated with
inpatient care.1,2 Renal dysfunction is common
in hospitalized patients.3 Many ADEs are
associated with the inappropriate use of renally
cleared medications in patients with renal
dysfunction.4,5 A multidisciplinary committee
was formed and alerts were developed to assist
clinicians in the safe use of these
medications. The first decision support was the
provision of an automated estimate of a patients
creatinine clearance. Alerts were then developed
to warn clinicians during CPOE of the need for
assessment of renal function, dosage adjustment
or contraindication. The system then monitors
all newly reported renal function and makes
suggestions regarding the need for re-dosing, new
contraindication and potential nephrotoxicity.
Development and implementation required
cooperative work by the Medical staff, Pharmacy,
IT and Nursing. The system of alerts interacts
with clinicians frequently with very little
complaints from the clinicians. Initial analysis
shows a clear benefit of the alerts for
contraindication. Initial analysis of the dosage
related alerts at the time of CPOE show some
benefits in appropriate dosing. More analysis
needs to occur to examine the full benefits of
the system of alerts and recommendations.
Medications on Formulary Impacted by Renal
Function
Creatinine Clearance
EFFECT ON CONTRAINDICATED DRUG USE
Estimated Clearance of Alert Intercepted Med
Orders Contraindicated Due to Renal Insufficiency
70
Normal Function
DEVELOPMENT OF CREATININE CLEARANCE ESTIMATE
60
Mild Dysfunction
50
(from Cockroft Gault6)
Trigger
New Serum Cr level resulted
40
Creatinine Clearance
Y
Age lt17 yrs?
DONE
30
N
Y
Active order for hemodialysis or peritoneal
dialysis?
DONE
Mod Dysfunction
20
N
Y
N
Male?
Height is available?
CrCl(140-age)/(Serum Cr)
Severe Dysfunction
10
Y
N
CrCl(140-age)/(Serum Cr).85
0
0
2
4
6
8
10
12
14
Y
N
Months in Production
Male?
CrCl((140-age)50)/((Serum Cr)72)
Height gt 1.524 m?
REFERENCES
N
Y
CrCl((140-age)45)/((Serum Cr)72).85
1 Bates DW, Spell N, Cullen DJ, et al. The
costs of adverse drug events in hospitalized
patients. JAMA 1997277(4)307-311. 2 Classen
DC, Pestotnik SL, Evans S, et al. Adverse drug
events in hospitalized patients. JAMA
1997277(4)301-306. 3 Chertow GM, Lee J,
Kuperman GJ, et al. Guided medication dosing for
inpatients with renal insufficiency. JAMA. 2001
286( 22) 2839-2844. 4 Lesar TS, Briceland L,
Stein DS. Factors related to errors in medication
prescribing. JAMA. 1997 Jan 22-29277(4)312-7.
5 Huff ED. Systems analysis of adverse drug
events. JAMA. 1996 Jan 3275(1)33-4 6
Cockcroft DW, Gault MH. Prediction of creatinine
clearance from serum creatinine. Nephron
1631-41, 1976.
Y
CrCl((140-age)IBW)/((Serum Cr)72)
Male?
N
IBW
502.3(Height-1.524)/.0254
CrCl((140-age)IBW)/((Serum Cr)72).85
male
IBW
452.3(Height-1.524)/.0254
female
Enter CrCl estimate into database