Real-time pharmacy surveillance and clinical decision support to reduce adverse drug events in acute kidney injury: a randomized, controlled trial

Abstract

OBJECTIVES: Clinical decision support (CDS), such as computerized alerts, improves prescribing in the setting of acute kidney injury (AKI), but considerable opportunity remains to improve patient safety. The authors sought to determine whether pharmacy surveillance of AKI patients could detect and prevent medication errors that are not corrected by automated interventions. METHODS: The authors conducted a randomized clinical trial among 396 patients admitted to an academic, tertiary care hospital between June 1, 2010 and August 31, 2010 with an acute 0.5 mg/dl change in serum creatinine over 48 hours and a nephrotoxic or renally cleared medication order. Patients randomly assigned to the intervention group received surveillance from a clinical pharmacist using a web-based surveillance tool to monitor drug prescribing and kidney function trends. CDS alerting and standard pharmacy services were active in both study arms. Outcome measures included blinded adjudication of potential adverse drug events (pADEs), adverse drug events (ADEs) and time to provider modification or discontinuation of targeted nephrotoxic or renally cleared medications. RESULTS: Potential ADEs or ADEs occurred for 104 (8.0%) of control and 99 (7.1%) of intervention patient-medication pairs (p=0.4). Additionally, the time to provider modification or discontinuation of targeted nephrotoxic or renally cleared medications did not differ between control and intervention patients (33.4 hrs vs. 30.3 hrs, p=0.3). CONCLUSIONS: Pharmacy surveillance had no incremental benefit over previously implemented CDS alerts.

Fig. 1

Surveillance view of real-time tool for monitoring acute kidney injury patients and clinical decision support interactions.

Fig. 2

Patient detail view of real-time tool for monitoring acute kidney injury patients and clinical decision support interactions.

Fig. 3

Flow diagram of control and intervention cases. Prior to analysis, a blinded outcomes assessment pharmacist evaluated cases for additional exclusion criteria that could not be determined electronically at the time of randomization.

Fig. 4

Kaplan-Meier curves for time to provider response. Follow-up began at the initial 0.5 mg/dl serum creatinine change for pre-trigger medications (ordered prior to the serum creatinine change) and at ordertime for post-trigger medications (ordered after the serum creatinine change).