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Aims: Computerized decision support systems (CDSSs) aim to prevent adverse drug events. However, these systems generate an overload of alerts that are not always clinically relevant. Anticoagulants are frequently involved in these alerts. The aim of this study was to investigate the efficiency of CDSS alerts on anticoagulants in Dutch hospital pharmacies. Methods: A multicentre, single‐day, cross‐sectional study was conducted using a flashmob design in Dutch hospital pharmacies, which have CDSSs that operate on both a national medication surveillance database and on self‐developed clinical rules. Hospital pharmacists and pharmacy technicians collected data on the number and type of alerts and time needed for assessing these alerts. The primary outcome was the CDSS efficiency on anticoagulants, defined as the percentage of alerts on anticoagulants that led to an intervention. Secondary outcomes where among other CDSSs efficiency related to any medications and the time expenditure. Descriptive data‐analysis was used. Results: Of the 69 hospital pharmacies invited, 42 (61%) participated. The efficiency of CDSS alerts on anticoagulants was 4.0% (interquartile range [IQR] 14.0%) for the national medication surveillance database alerts and 14.3% (IQR 40.0%) for alerts from clinical rules. For any medication, the efficiency was lower: 1.8% (IQR 7.5%) and 13.4% (IQR 21.5%) respectively. The median time for assessing the relevance of all alerts was 2 (IQR 1:21) h/day for pharmacists and 6 (IQR 5:01) h/day for pharmacy technicians. Conclusion: CDSS efficiency is generally low, both for anticoagulants and any medication, while the time investment is high. Optimization of CDSSs is needed. [ABSTRACT FROM AUTHOR]

Background Methods Results Conclusion Multiple trigger tools have been developed to identify medication‐related hospital (re)admissions (MRRs); however, the accuracy of these tools in real‐world clinical practice is uncertain. The objective of this study was to compare the accuracy of four different trigger tools (OPERAM, STOPP/START criteria, ADR‐tool, and QUADRAT) to identify MRRs compared with clinical adjudication.We conducted a secondary analysis of patients readmitted within 30 days to seven departments of a teaching hospital. In the primary study, which involved a retrospective chart review of 1111 readmissions, MRRs and their potential preventability were clinically adjudicated by physicians and pharmacists. In the current study, four trigger tools were applied by a different physician and pharmacist panel. Patients of all ages were included. Trigger tools included both explicit items specifying the event and the associated medication and implicit items requiring clinical knowledge. The accuracy of each trigger tool was assessed by calculating the proportion of clinically adjudicated MRRs each tool identified overall as well as according to explicit and implicit triggers separately. The accuracy of each tool to identify potentially preventable MRRs was also calculated.Of 1111 readmissions, 181 were adjudicated as medication‐related (mean age 69 years, 56% male); 72 (40%) MRRs were potentially preventable. The original OPERAM tool identified 166 (92%) MRRs (62% through explicit triggers). The STOPP/START criteria identified 23 (13%, 7% through explicit triggers), the ADR tool identified 51 (28%, all explicit triggers), and the QUADRAT tool identified 76 (42%; all explicit triggers) MRRs. Of the 72 potentially preventable MRRs, OPERAM identified 59 (82%), STOPP/START identified 18 (25%), ADR identified 20 (28%), and QUADRAT identified 21 (29%).The original OPERAM tool identified the highest proportion of (preventable) MRRs. However, this tool includes many implicit triggers requiring expert clinical knowledge. Future studies should assess the practicality of implementing this tool in daily practice. [ABSTRACT FROM AUTHOR]

Antithrombotics require careful monitoring to prevent adverse events. Safe use can be promoted through so-called antithrombotic stewardship. Clinical decision support systems (CDSSs) can be used to monitor safe use of antithrombotics, supporting antithrombotic stewardship efforts. Yet, previous research shows that despite these interventions, antithrombotics continue to cause harm. Insufficient adoption of antithrombotic stewardship and suboptimal use of CDSSs may provide and explanation. However, it is currently unknown to what extent hospitals adopted antithrombotic stewardship and utilize CDSSs to support safe use of antithrombotics. A semi-structured questionnaire-based survey was disseminated to 12 hospital pharmacists from different hospital types and regions in the Netherlands. The primary outcome was the degree of antithrombotic stewardship adoption, expressed as the number of tasks adopted per hospital and the degree of adoption per task. Secondary outcomes included characteristics of CDSS alerts used to monitor safe use of antithrombotics. All 12 hospital pharmacists completed the survey and report to have adopted antithrombotic stewardship in their hospital to a certain degree. The median adoption of tasks was two of five tasks (range 1-3). The tasks with the highest uptake were: drafting and maintenance of protocols (100%) and professional's education (58%), while care transition optimization (25%), medication reviews (8%) and patient counseling (8%) had the lowest uptake. All hospitals used a CDSS to monitor safe use of antithrombotics, mainly via basic alerts and less frequently via advanced alerts. The most frequently employed alerts were: identification of patients using a direct oral anticoagulant (DOAC) or a vitamin K antagonist (VKA) with one or more other antithrombotics (n = 6) and patients using a VKA to evaluate correct use (n = 6), both reflecting basic CDSS. All participating hospitals adopted antithrombotic stewardship, but the adopted tasks vary. CDSS alerts used are mainly basic in their logic., Competing Interests: I have read the journal’s policy and the authors of this manuscript have the following competing interests: RH is a CMO at Gaston Medical which is a software company that develops medical decision support systems. The other authors report no conflicts., (Copyright: © 2024 Graafsma et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.)

Background: Medication errors occur frequently at points of transition in care. The key problems causing these medication errors are: incomplete and inappropriate medication reconciliation at hospital discharge (partly arising from inadequate medication reconciliation at admission), insufficient patient information (especially within a multicultural patient population) and insufficient communication to the next health care provider. Whether interventions aimed at the combination of these aspects indeed result in less discontinuity and associated harm is uncertain. Therefore the main objective of this study is to determine the effect of the COACH program (Continuity Of Appropriate pharmacotherapy, patient Counselling and information transfer in Healthcare) on readmission rates in patients discharged from the internal medicine department., Methods/design: An experimental study is performed at the internal medicine ward of a general teaching hospital in Amsterdam, which serves a multicultural population. In this study the effects of the COACH program is compared with usual care using a pre-post study design. All patients being admitted with at least one prescribed drug intended for chronic use are included in the study unless they meet one of the following exclusion criteria: no informed consent, no medication intended for chronic use prescribed at discharge, death, transfer to another ward or hospital, discharge within 24 hours or out of office hours, discharge to a nursing home and no possibility to counsel the patient.The intervention consists of medication reconciliation, patient counselling and communication between the hospital and primary care healthcare providers.The following outcomes are measured: the primary outcome readmissions within six months after discharge and the secondary outcomes number of interventions, adherence, patient's attitude towards medicines, patient's satisfaction with medication information, costs, quality of life and finally satisfaction of general practitioners and community pharmacists.Interrupted time series analysis is used for data-analysis of the primary outcome. Descriptive statistics is performed for the secondary outcomes. An economic evaluation is performed according to the intention-to-treat principle., Discussion: This study will be able to evaluate the clinical and cost impact of a comprehensive program on continuity of care and associated patient safety., Trial Registration: Dutch trial register: NTR1519.

Background: Hospital admissions are a risk factor for the occurrence of unintended medication discrepancies between drugs used before admission and after discharge. To diminish such discrepancies and improve quality of care, medication reconciliation has been developed. The exact contribution of patient counseling to the medication reconciliation process is unknown, especially not when compared with community pharmacy medication records, which are considered reliable in the Netherlands., Objective: To examine the effect of medication reconciliation with and without patient counseling among patients at the time of hospital discharge on the number and type of interventions aimed at preventing drug-related problems., Methods: A prospective observational study in a general teaching hospital was performed. Patients discharged from the pulmonology department were included. A pharmacy team assessed the interventions with and without patient counseling on discharge medications for each patient., Results: Two hundred sixty-two patients were included. Medication reconciliation without patient counseling was responsible for at least one intervention in 87% of patients (mean 2.7 interventions/patient). After patient counseling, at least one intervention (mean 5.3 interventions/patient) was performed in 97% of patients. After patient counseling, discharge prescriptions were frequently adjusted due to discrepancies in use or need of drug therapy. Most interventions led to the start of medication due to omission and dose changes due to incorrect dosages being prescribed. Patients also addressed their problems/concerns with use of the drug, which were discussed before discharge., Conclusions: Significantly more interventions were identified after patient counseling. Therefore, patient information is essential in medication reconciliation.