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 |