Background 49% of adverse drug events are due to ordering and prescribing errors. Pharmacists play a key role in providing drug information to other caregivers to reduce adverse events and improve patient safety.

Purpose Analysis of pharmacists’ interventions during drug order validation after implementation of standardised drug information in a computerised physician order entry system (CPOE). To evaluate its added value and further information needs.

Material and methods Integration of structured and standardised drug information in a CPOE system and on the hospital’s intranet was performed in a 500 bed regional hospital. Implementation of systematic drug order validation prior to dispensing by trained hospital pharmacists was studied in a retrospective analysis of pharmacists’ interventions.

Results To guide prescribing, we translated existing predefined drug orders in our CPOE as part of a preliminary clinical decision support system. These schemes comprised multiple drugs in relation to specific procedures or diagnosis (eg, postoperative pain protocols) and schemes for intravenous (IV) drug administration (including correct infusion bag and duration of administration). In addition, drug specific information concerning crushing of oral dosage forms, schemes for IV drugs, antibiotic monographs and leaflets for new formulary drugs were made available on the hospital’s intranet. Prior to drug dispensing, the pharmacist performs a systematic drug order validation, with the aid of the integrated drug information. The pharmacist checks, among other items, correct drug dosing and administration modalities, drug therapy in relation to known drug allergies and contraindicated drug interactions (eg, meropenem–valproate, low molecular weight heparin (LMWH) at the same time as novel anticoagulants (NOAC)).

Over a 4 month period, 119 pharmacists’ interventions were registered. Most common reasons for intervention were adjustment of drug dose or frequency (31%), drug prescribed for which an allergy was documented in the medical record (21%), adjustment of IV drug administration (16%), duplicate therapy (16%) and LMWH–NOAC interaction (8%). Overall acceptance rate of pharmacist advice was 88%.

Conclusion Integration of standardised drug information in existing computerised systems in combination with patient tailored advice by the hospital pharmacist improves the quality and safety of drug orders and administrations for hospitalised patients. Analysis of pharmacists’ interventions provides valuable information to continuously improve our drug information service.

References and/or acknowledgements Kaushal R. Arch Int Med2003;163:1409–16.

No conflict of interest