Benefit of medication reviews by renal pharmacists in the setting of a computerized physician order entry system with clinical decision support

Abstract

What Is Known and Objective A ‘renal pharmacist consultant service’ (RPCS) reviewing patients' charts with renal impairment (RI) for drug‐related problems (DRP) can foster patient safety. However, the benefit of this service in the new setting of a computerized physician order entry (CPOE)‐system with a clinical decision support (CDS)‐system is unknown. The aim of our study was to evaluate the general need for an RPCS on wards with a CPOE‐CDS‐system already in use and its effectiveness on prescription changes to ensure in‐hospital patient safety. Methods Over a period of 3 months (02‐04/2021), elective orthopaedic and trauma patients with eGFRabsolute/CrCl <60 ml/min at a German University Hospital received a medication review by a renal pharmacist for all medication entered into the CPOE‐system (Meona®) by the treating physicians. Written consultations explaining identified DRP and recommending interventions to solve them, for example, dose or drug adaptation, were shared with the physicians directly in the drug chart tab of Meona®. In complex cases, DRP were additionally discussed via phone. The prescription changes were evaluated retrospectively. Results and Discussion During 53 working days, 712 (30.5%) of 2331 screened patients were included with an eGFRnon‐indexed/CrCl <60 ml/min and a pharmacist‐led medication review was performed for all medication presented in the CPOE‐system (Meona®). In 79 of 712 (11.1%) patients, one or more DRP were detected (median 1 DRP (1–3) per patient) and written recommendations concerning 106 of 1090 (9.7%) drugs were shared via Meona®. In total, 104 DRP were identified, mostly caused by ‘dosage too high’ (n = 55, 52.9%), ‘dosage regime wrong’ (n = 13, 12.5%), and ‘contraindication’ (n = 9, 8.7%). Acceptance rate of recommendations was 74.0% (n = 77/104). In nine cases (8.7%), despite of specific recommendations, no adjustment of drugs was made because of lack of alternatives. In 11 (10.6%) cases, prescription remained unchanged for unknown reasons and in seven (6.7%) cases, the result was unknown due to discharge. What Is New and Conclusion In the setting of prescribing in a CPOE‐CDS‐system, that provides physicians with advice for drug or dose adaption, the pharmacist‐led medication reviews still identified DRP in orthopaedic and trauma patients with RI. A RPCS forwarding recommendations to solve DRP via the electronic medical record increased appropriate prescribing by physicians and, thus, may further improve patient safety.

Comparison of Drug-Related Problems in COVID-19 and Non-COVID-19 Patients Provided by a German Telepharmacy Service for Rural Intensive Care Units

“…This highly corresponds to the results at hand. In addition, renal pharmacists have been implemented in different countries to account for the special risks for DRPs in this patient group [50,51].…”

Interprofessional Evaluation of a Medication Clinical Decision Support System Prior to Implementation

“…Data on the usefulness of Meona as a medication CDSS in clinical routine are scarce. 39 40 41 For instance, Amkreutz et al 40 only performed an evaluation of the drug–drug interaction check but none of the investigations performed a detailed evaluation of the entire medication CDSS integrated in Meona.…”

Overcoming Barriers in Nurse-Pharmacist Collaborations on Wards – Qualitative Expert Interviews with Nurses and Pharmacists

“…Concerning the clinical-pharmaceutical activities of pharmacists in hospitals, the benefits for patient safety in practice and clinical trials are increasingly recognized. [24][25][26][27] It should be further explored how pharmacotherapy on a patient-individual level might be improved by structuring collaboration between professional groups of pharmacists and nurses exceeding logistics. Furthermore, it has to be evaluated how the adaption of concepts to the needs and resources of individual settings can be managed.…”