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Table 4 CDSS notifications assessed as non-relevant but confirmed as relevant

From: The support of medication reviews in hospitalised patients using a clinical decision support system

DRP notifications

DRP strategy in handmade medication review

Reason assessed as non-relevant notification and improvement suggestion

Potassium levels—drugs inducing hyperkalemia

Stop potassium supplement with potassium level of 3.9

Cut-off point for potassium (>5.5 mmol/l) was not reached. Cut-off point needs to be refined

Benzodiazepines and fall risk

Stop or dose benzodiazepine ‘as needed’

Phase out benzodiazepine

Benzodiazepine usage should be stopped or reassessed when chronic

A predictive risk algorithm for falling might be developed

Paracetamol in elderly patients in combination with risk factors

Stop paracetamol because of medication induced headaches

Include code of International Statistical Classification of Diseases into algorithm

Nortriptyline in elderly: the maximum daily dose in elderly is 50 mg. If nortriptyline is dosed higher, an ECG and monitoring of nortriptyline levels is recommended

No strategy

Two separate prescriptions of nortriptyline: 10 mg and 50 mg. The two prescriptions should be combined by the CDSS to show the total dosage

Paracetamol in elderly in combination with risk factors

Chronic use of paracetamol should be reduced to a maximum of 3 g daily

Chronic paracetamol usage in higher dosages should be avoided. Additional risk factors should be included in the algorithm alongside the dosage

Renal Failure and Amoxicillin/Clavulanic acid (oral)

Renal function 32 ml/min and oral dosage amoxicillin/clavulanic acid increased

Too low dosages when renal function improves should be included in the algorithm

Alendronic acid usage longer than 5 years

Consider whether continuation after 5 years of use is necessary

The original prescription starting date was not taken into account when patient was admitted to hospital

Citalopram in elderly

Prescribed dosage 30 mg, maximum dosage in elderly 20 mg

Two separate prescriptions citalopram; 10 and 20 mg. The two prescriptions should be combined by the CDSS in order to the total dosage

Anticoagulation therapy and INR

Increase dosage since INR is too low

The upper limit cut-off point for >5.5 INR was not reached. The algorithm focusses on toxicity, while for medication reviews a lower limit should also be included to monitor therapeutic efficacy

Potassium levels—drugs inducing hyperkalemia

Elevated potassium level of 4.6 with Losartan (which contains potassium). Converted to another ATII-antagonist

Cut-off point is set to trigger when potassium > 5.5 mmol/l. The specific prescription of losartan is not included in the algorithm of drugs containing potassium

Opioids without laxative agents. Up to 70 % of the patients using opioids experience opioid-induced constipation

Restart laxative agents when diarrhea has stopped

Prescription of laxative agents is temporarily stopped, but remains in the medication extraction.

Temporarily stopped drugs should not be included in extraction. An indicator for bowel movement (stool) might be introduced