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Background Adverse drug events (ADEs) can be prevented by deploying clinical decision support systems (CDSS) that directly assist physicians, via computerized order entry systems, and clinical pharmacists performing medication reviews as part of medical rounds. However, physicians using CDSS are known to be exposed to the alert-fatigue phenomenon. Our study aimed to assess the performance of PharmaCheck—a CDSS to help clinical pharmacists detect high-risk situations with the potential to lead to ADEs—and its impact on clinical pharmacists’ activities. Methods Twenty clinical rules, divided into four risk classes, were set for the daily screening of high-risk situations in the electronic health records of patients admitted to our General Internal Medicine Department. Alerts to clinical pharmacists encouraged them to telephone prescribers and suggest any necessary treatment adjustments. PharmaCheck’s performance was assessed using the intervention’s positive predictive value (PPV), which characterizes the proportion of interventions for each alert triggered. PharmaCheck’s impact was assessed by considering clinical pharmacists as a filter for ruling out futile alerts and by comparing the final clinical PPV with a pharmacist (the proportion of interventions that led to a change in the medical regimen) to the final clinical PPV without a pharmacist. Results Over 132 days, 447 alerts were triggered for 383 patients, leading to 90 interventions (overall intervention PPV = 20.1%). By risk class, intervention PPVs made up 26.9% (n = 65/242) of abnormal laboratory value alerts, 3.1% (4/127) of alerts for contraindicated medications or medications to be used with caution, 28.2% (20/71) of drug–drug interaction alerts, and 14.3% (1/7) of inadequate mode of administration alerts. Clinical PPVs reached 71.0% (64/90) when pharmacists filtered alerts and 14% (64/242) if they were not doing it. Conclusion PharmaCheck enabled clinical pharmacists to improve their traditional processes and broaden their coverage by focusing on 20 high-risk situations. Alert management by pharmacists seemed to be a more effective way of preventing risky situations and alert-fatigue than a model addressing alerts to physicians exclusively. Some fine-tuning could enhance PharmaCheck's performance by considering the information quality of triggers, the variability of clinical settings, and the fact that some prescription processes are already highly secured.

Background and importance In the internal medicine department of our hospital, medication review provided by pharmacists during medical rounds is offered to only a fraction of the 200 inpatients, due to limited resources. In order to detect high risk situations potentially leading to adverse drug events, we developed PharmaCheck, an electronic tool that screens all patient electronic health records (EHR) in real time, by aggregating drug prescriptions, laboratory values, vital signs and medical problems. Aim and objectives To determine the impact of PharmaCheck in the identification of high risk situations and on the clinical pharmacist’s interventions. Material and methods PharmaCheck was set to screen 20 situations distributed into four risk classes: a drug prescription with an abnormal laboratory value, a contraindication, a drug–drug interaction (DDI) and an inadequate administration mode. For 150 days (February to August 2020), PharmaCheck performed a daily screen of patients’ EHR, admitted to the internal medicine department. As soon as an alert was triggered, the clinical pharmacist analysed the patient’s clinical context to suggest a treatment adjustment when needed. An observational prospective study was performed to assess the distribution of each risk class, the predictive positive value of each alert (PPV: proportion of situations associated with an intervention) as well as the acceptance rate by the prescribers. Results 430 alerts were triggered for 387 patients (3.3±1.9 alerts/day) with a global PPVof 19.3% (n=83/430). Regarding risk classes, PPVs were 25.6% (n=58/226) for abnormal laboratory value, 3.10% (4/127) for contraindications, 28.2% (20/71) for DDIs and 16.7% (1/6) for inadequate administration mode. The approval rate of treatment adjustment suggestions was 71.1% (n=59/83); rejections were related to an acceptable risk–benefit balance (n=20) or an unknown cause (n=4). Conclusion and relevance PharmaCheck identified a significant number of high risk situations. By contextualising these alerts the clinical pharmacist selected the most relevant ones to suggest treatment adjustment, mostly accepted by physicians. Beyond the clinical context, the relevance of alerts depends on the informative quality of the triggering elements, explaining a low PPV for some risk classes (eg, contraindication, depending on unstructured textual medical problems). PharmaCheck expands the coverage of the clinical pharmacist for selected situations and we plan to transpose this strategy to other, more fragile, patient populations (eg, geriatrics, paediatrics, oncology). References and/or acknowledgements Conflict of interest No conflict of interest

During Switzerland's first wave of COVID-19, clinical pharmacy activities during medical rounds in Geneva University Hospitals were replaced by targeted remote interventions. We describe using the electronic PharmaCheck system to screen high-risk situations of adverse drug events (ADEs), particularly targeting prescriptions of lopinavir/ritonavir (LPVr) and hydroxychloroquine (HCQ) in the presence of contraindications or prescriptions outside institutional guidelines. Of 416 patients receiving LPVr and/or HCQ, 182 alerts were triggered for 164 (39.4%) patients. The main associated risk factors of ADEs were drug-drug interactions, QTc interval prolongation, electrolyte disorder and inadequate LPVr dosage. Therapeutic optimisation recommended by a pharmacist or proposals for additional monitoring were accepted in 80% (n=36) of cases. Combined with pharmacist contextualisation to the clinical context, PharmaCheck made it possible to successfully adapt clinical pharmacist activities by switching from a global to a targeted analysis mode in an emergency context.

Computerised provider order entry is becoming a major factor in the field of electronic patient records, and a growing number of publications are addressing its numerous aspects. However, few studies have highlighted the importance of a global order entry platform capable of dealing with all orders needed for patient care and not only drug orders. In addition, a system of this kind must make it possible to group orders relating to a specific problem and avoid management of a list of single elementary orders which cannot reflect the clinical decision-making process. Finally, it is in the context of a process devoted to the global care of a patient, definable in a clinical pathway, that maximum benefit, with regard to quality, safety and economic efficiency, can be derived from computerised provider order entry.