To cite this article: Kucher N, Puck M, Blaser J, Bucklar G, Eschmann E, Lü scher TF. Physician compliance with advanced electronic alerts for preventing venous thromboembolism among hospitalized medical patients. J Thromb Haemost 2009; 7: 1291-6. Summary. Background: Worldwide, more than half of the hospitalized medical patients at high risk do not receive venous thromboembolism (VTE) prophylaxis. Although VTE among hospitalized patients at risk is reduced with electronic alerts (eAlerts), the majority of eAlerts are being ignored by the responsible physician. Methods: We investigated physician compliance with an advanced eAlert system in 1027 (age 59 ± 17 years) hospitalized medical patients. A continuously flashing non-interruptive eAlert, visible to all healthcare professionals, was issued in the electronic patient chart 6 h after admission if the physician did not order prophylaxis. Results: The rate of appropriate prophylaxis increased from 44% before to 76% after the implementation of the eAlert system. Although the patients whose physicians cared for ‡ 20 patients during the study period had a more frequent physician response to the eAlert than patients whose physicians cared for fewer patients (69% vs. 40%, P < 0.001), they received appropriate prophylaxis less often (72% vs. 81%, P = 0.016). After adjustment for significant patient predictors of appropriate prophylaxis, including cancer, age, duration of hospital stay, and thrombocytopenia, patients whose physicians cared for ‡ 20 patients during the study period were less likely to receive appropriate prophylaxis (odds ratio 0.65, 95% confidence interval 0.44-0.96; P = 0.032) than patients whose physicians cared for fewer patients. Conclusions: The introduction of an advanced eAlert system accompanied by continuing medical education for the prevention of VTE resulted in a substantial increase in the rate of appropriate prophylaxis among hospitalized medical patients. However, many eAlerts may cause decreased physician compliance owing to Ôalert fatigueÕ.

PURPOSE Overdosing of the oral antidiabetic metformin in impaired renal function is an important contributory cause to life-threatening lactic acidosis. The presented project aimed to quantify and prevent this avoidable medication error in clinical practice. METHODS We developed and implemented an algorithm into a hospital's clinical information system that prospectively identifies metformin prescriptions if the estimated glomerular filtration rate is below 60 mL/min. Resulting real-time electronic alerts are sent to clinical pharmacologists and pharmacists, who validate cases in electronic medical records and contact prescribing physicians with recommendations if necessary. RESULTS The screening algorithm has been used in routine clinical practice for 3 years and generated 2145 automated alerts (about 2 per day). Validated expert recommendations regarding metformin therapy, i.e., dose reduction or stop, were issued for 381 patients (about 3 per week). Follow-up was available for 257 cases, and prescribers' compliance with recommendations was 79%. Furthermore, during 3 years, we identified eight local cases of lactic acidosis associated with metformin therapy in renal impairment that could not be prevented, e.g., because metformin overdosing had occurred before hospitalization. CONCLUSIONS Automated sensitive screening followed by specific expert evaluation and personal recommendations can prevent metformin overdosing in renal impairment with high efficiency and efficacy. Repeated cases of metformin-associated lactic acidosis in renal impairment underline the clinical relevance of this medication error. Our locally developed and customized alert system is a successful proof of concept for a proactive clinical drug safety program that is now expanded to other clinically and economically relevant medication errors. Conflict of interest statement: This study was supported by unrestricted grants to StefanRussmann from the Swiss National Science Foundation (grant #320030_143867) and ID Suisse AG. The manuscript was made available to ID Suisse before submission, but ID Suisse had no influence on the study design, analysis, or interpretation of the results. All authors declare that they have no disclosures and conflict of interest in relation to the presented study. Key Points• Metformin-associated lactic acidosis is a rare but potentially fatal adverse event.Incident comorbidities and lack of metformin dose-adjustment in renal impairment are important contributing and triggering factors.• We developed and implemented an automated alert with highly sensitive prospective screening for metformin prescriptions in renal impairment into the clinical information system of a tertiary care hospital. Local safety experts validated resulting alerts and issued specific recommendations that effectively prevented inappropriate metformin administrations in renal impairment.• The presented concept of "semi-automated" alerts can be applied to the prevention of further clinically and economically relevant medication errors....

In healthy subjects, inductance cardiography accurately and unobtrusively estimates changes in cardiac output during bicycle exercise in comparison to gas exchange methods.

Abstract--Inductance cardiography (thoracocardiography) non-invasive/y monitors

WHAT IS KNOWN AND OBJECTIVES Paracetamol is a frequently used antipyretic and analgesic drug, but also a dose-dependent hepatotoxin. Unintentional paracetamol overdosing is a common medication error in hospitals. The present study aimed at (i) analysis of unintentional paracetamol overdosing in hospitalized patients; (ii) development, implementation and outcome analysis of an alert algorithm for the prevention of relevant paracetamol overdosing. METHODS All patients who received paracetamol in a Swiss tertiary care hospital during 2011 to 2014 were analysed to detect cases of paracetamol overdosing in a local pharmacoepidemiological database. In 2014, an automated algorithm screened the hospital's electronic prescribing system for patients at risk of overdosing, followed by expert validation. When imminent relevant overdosing was confirmed, alerts were issued to prescribers. Relevance was defined as prescriptions that permitted repeated daily paracetamol exposure of 5 g. RESULTS AND DISCUSSION From 2011 to 2013, relevant overdosing occurred in 11 patients (5-8 g/day for 3 to 5 days), which corresponds to 0·4 % of all patients exposed to any paracetamol overdosing (mean n = 988 per year). In 2014, alerts were issued by experts in 23 cases with subsequent changes to prescriptions in 21 (91·3 %) thereof. Although the occurrence of any paracetamol overdosing declined only marginally in 2014 (n = 914), no relevant overdosing occurred anymore. WHAT IS NEW AND CONCLUSION Unintentional paracetamol overdosing was frequent but only a small fraction thereof was deemed relevant. This proof of concept study analysed local hospital data and developed a preventive system combining sensitive automated detection with subsequent specific expert validation. The resulting alerts achieved high compliance and prevented relevant paracetamol overdosing. SUMMARYWhat is known and objectives: Paracetamol is a frequently used antipyretic and analgesic drug, but also a dose-dependent hepatotoxin. Unintentional paracetamol overdosing is a common medication error in hospitals. The present study aimed at 1)Analysis of unintentional paracetamol overdosing in hospitalized patients; 2)Development, implementation and outcome of an alert algorithm for the prevention of considerable paracetamol overdosing. Methods:All patients who received paracetamol in a Swiss tertiary care hospital during 2011 to 2014 were analysed to detect cases of paracetamol overdosing in a local pharmacoepidemiological database. In 2014 an algorithm screened the hospital's electronic prescribing system for patients at risk of considerable overdosing, followed by expert validation. When such overdosing was confirmed as imminent, alerts were issued to prescribers. Considerable overdosing was defined as prescriptions that permitted repeated daily paracetamol exposure of ≥ 5 g. Results and What is new and Conclusion:This proof of concept demonstrates that analyzing local hospital data allows the development of alert algorithms that successfully prevent relevant medi...