AIM: CPOE + alerts reduce adverse drug events in elderly patients

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A computerized provider order entry (CPOE) system with programmed alerts can significantly reduce doctors’ orders for drugs that pose a danger to older patients, according to a report in the Aug. 9/23 issue of the Archives of Internal Medicine.

Adverse drug events, such as dizziness or confusion, occur in an estimated 40 percent of all hospital patients and can be the result of inappropriate medications being ordered, according to researchers at Beth Israel Deaconess Medical Center (BIDMC) in Boston. Elderly individuals are particularly vulnerable to these adverse events, which not only result in longer hospitalizations, but can also pose a threat of serious complications and even death.

“[C]ertain commonly prescribed drugs can be harmful to older patients,” wrote lead author Melissa Mattison, MD, geriatrician and associate director of hospital medicine at BIDMC. “But because the majority of doctors have not been trained in geriatric medicine, they may not be aware of these risks. Our study found that when doctors were alerted that the drugs they were ordering could pose a danger to older hospital patients, the orders dropped almost immediately.”

In 2004, Mattison and colleagues began work to develop a specialized version of the CPOE system that could be used to help doctors in prescribing medications for elderly patients. The new system uses components of the Beers List, which was developed by physician Mark Beers in 1993 to draw attention to dozens of common drugs that should be prescribed “with caution” to elderly patients.

“Many drugs commonly used today have not been tested in seniors or elderly patients,” explained Mattison. “As a result, a dose that is appropriate for a younger adult may lead to potentially harmful side effects in older individuals, who tend to metabolize medications more slowly.” Additionally, seniors and elders are often already taking multiple medications, resulting in a situation that can predispose seniors to potentially dangerous side effects.

To avoid user fatigue, the authors selected a small group of 18 medications from the Beers list that are commonly prescribed in the inpatient hospital setting and for which alternative medications were available.

Since 2005, doctors at BIDMC who attempted to order one of these 18 Beers drugs for a patient 65 years of age or older, received a warning on their computer screen, informing them of potential risks. Although the doctor can override the warning and continue to prescribe the medication, he or she must provide an explanation for the decision, which is selected from a list that is provided by the system. For three and a half years, the researchers measured the number of orders of the 18 selected Beers medications that were made each day and monitored the use of several medications that were part of the original Beers List, but were not flagged in the warning system.

Results showed that orders for flagged medications dropped from 11.56 to 9.94 total orders per day, and dropped from 0.070 to 0.045 orders per total number of patients per day, amounting to a decrease of approximately 20 percent in the use of flagged medications. The number of orders for unflagged medications did not change, the report found.

“To our knowledge, no CPOE system has previously been described that utilizes a warning system built around PIMs [potentially inappropriate medications] in older, hospitalized adults,” the authors concluded. “Up to 60 percent of adverse drug events occur at the time that medications are ordered. Using CPOE to guide care at the point of ordering – to steer clinicians to choose potentially better alternative medications and treatments – is an exciting opportunity to improve care for this vulnerable population.”

This study was supported, in part, by the National Center for Research Resources of the National Institutes of Health.