The Safety Net: How Clinical Decision Support Empowers Pharmacist Intervention

Medication-related harm, such as medication errors and adverse drug reactions, affects 1 out of every 30 patients, with more than a quarter of this harm regarded as severe or life-threatening. Half of the avoidable harm in health care is related to medications.^1,2

The synergy between the pharmacist’s expertise and clinical decision support software (CDSS) creates a safety net in which data-driven efficiency converges with the pharmacist’s human clinical judgment. CDSS supplies automated, real-time data that the pharmacist can interpret and translate into actionable patient care.³

This synergistic relationship creates a multilayered defense against error and can reduce medication errors and adverse drug reactions by 12.5%, preventing approximately 17.4 million medication errors within a single year.³

CDS

In the pharmacy, CDS consists of digital tools and computer programs designed to provide the pharmacist with the information required to make safer, more accurate medication-related decisions. These are also called pharmacy information systems (PISs). CDS includes prospective screening, concurrent management, and retrospective analysis of treatment.

Prospective screening includes “real-time checks for drug allergies, drug interactions, therapeutic duplication, and dose limits.” It can also include “formulary suggestions, look-alike/soundalike warnings, and prescription drug monitoring program integration.” Alternatively, options such as renal adjustment tools, intravenous-to-oral (IV-to-PO) drug conversion information, laboratory value correlation, and antimicrobial stewardship dashboards can be used when patients are already on therapy.⁴

Finally, retrospective CDS focuses on analyzing data after a medication has been dispensed. Retrospective queries allow pharmacists to provide broader safety oversight and quality improvement, and to identify trends in prescribing habits or high-risk patient populations.

Pharmacist Intervention

Pharmacist interventions with CDS tools are the bridge between automated data and clinical action. When the CDSS flags a potential issue, the pharmacist must use their expertise to interpret the alert and determine the safest course of action. Interventions typically occur in 3 phases: identification, evaluation, and resolution.²

• Identification: The identification phase often begins with the pharmacist receiving an alert from the PIS. This alert requires action from the pharmacist before they can continue with the prescription.
• Evaluation: The evaluation phase requires the pharmacist to determine the clinical significance of the alert. They must contextualize the data by determining whether the alert is warranted, then conduct a risk-benefit analysis. During this analysis, the pharmacist will determine whether it is safe to continue filling the medication or if a change is needed.
• Resolution: This final phase is where the pharmacist translates their clinical evaluation into a change in patient care. If the evaluation reveals a significant risk, the pharmacist contacts the prescriber. They do not simply report an alert; they provide specific solutions. Hospital pharmacists often have collaborative practice agreements that allow them to resolve certain alerts without consulting the prescriber. These can include renal dosing, IV-to-PO conversion, and others.

Documentation

Documenting pharmacist interventions through CDS is vital to providing measurable value that ensures medication safety and professional sustainability. Immediate documentation of pharmacist intervention is shared and prevents medication discrepancies during transitions of care, ensuring understanding of the intent behind clinical changes.⁵

Documentation also provides evidence of the impact pharmacists have on clinical and financial outcomes, helping to ensure funding and expand the scope of pharmacy practice. Furthermore, pharmacist documentation serves as a legally binding record of professional judgment, ensuring that clinical decisions can be defended during audits and/or litigation.

Finally, retroactively analyzing documented interventions enables organizations to optimize CDS logic, reducing alert fatigue and improving accuracy. Additionally, aggregated intervention data highlight areas where the system fails to detect risks that pharmacists identify manually.

Impact on Medication Safety

By combining automated, data-driven information with professional expertise, pharmacists can intervene to ensure medications are not only accurate but also therapeutically appropriate.

Integrated PIS tools help intercept medication errors and initiate pharmacist intervention at an early stage before harm comes to a patient. Medication errors have significantly decreased with the integration of CDS, with a reduction of over 96%.⁶ Some errors have even been virtually eliminated, such as wrong electronic selections, duplicate drugs, and drug-allergy conflicts.⁷

An effective medication safety surveillance system using CDS incorporates trajectory analysis and biomarkers to predict clinical events, rather than waiting for them to occur. Predictive models for adverse effects that include laboratory values can prevent harm; for example, monitoring kidney function while taking nephrotoxic medications.⁸

Finally, CDS tools can be used to optimize the use of high-risk medications. Advanced algorithms can be used to personalize insulin dosing, and drug-bug (antimicrobial/microbe) mismatches can be identified to ensure appropriate antibiotic stewardship.⁹

Overcoming Limitations

Pharmacist intervention via CDS tools is limited by desensitization and the inability of code to replace clinical judgment. According to researchers, pharmacists may override 46.2% to 96.2% of alerts provided by CDS tools as inconsequential.¹⁰ This “noise” can create mental exhaustion, leading to pharmacists ignoring critical warnings along with the inconsequential ones. In high-volume pharmacies, the increased frequency of data-driven alerts in turn increases the risk of inappropriate overrides.

Furthermore, algorithms are typically rule-based and process massive amounts of data, but lack the contextual reasoning and human connection required to know that an interaction is being intentionally managed or take a patient’s season of life into account regarding their treatment.

Smarter Pharmacy-Technology Partnerships

Pharmacy is a team sport between pharmacists and CDS systems. CDSS provides real-time, evidence-based insights that allow pharmacists to achieve proactive clinical interventions that improve medication safety through reducing medication errors and preventing adverse drug reactions. These interventions must be documented to increase medication safety, establish professional value, and defend clinical decisions.

Although there are some barriers to effective CDS integration, overcoming them will make the difference between remaining a reactive task-management profession and becoming a proactive clinical environment.

About the Author

Kathleen Kenny, PharmD, RPh, earned her doctoral degree from the University of Colorado Health Sciences Center. She has more than 30 years of experience as a community pharmacist and works as a clinical medical writer based in Albuquerque, New Mexico.

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