A System to Monitor and Improve Medication Safety in the Setting of Acute Kidney Injury

Abstract

Clinical decision support systems can decrease common errors related to inadequate dosing for nephrotoxic or renally cleared drugs. Within the computerized provider order entry (CPOE) system, we developed, implemented, and evaluated a set of interventions with varying levels of workflow intrusiveness to continuously monitor for and alert providers about acute kidney injury. Passive alerts appeared as persistent text within the CPOE system and on rounding reports, requiring no provider response. Exit check alerts interrupted the provider at the end of the CPOE session, requiring the provider to modify or discontinue the drug order, assert the current dose as correct, or defer the alert. In the intervention period, the number of drugs modified or discontinued within 24 hours increased from 35.7% to 50.9%, and the median time to modification or discontinuation decreased from 27.1 hours to 12.9 hours. Providers delayed decisions by repeatedly deferring the alerts. Future enhancements will address frequent deferrals by involving other team members in making mid-regimen prescription decisions.