Background and importance A ‘renal pharmacist consultant service’ (RPCS) reviewing patients with renal impairment (RI) for drug-related problems (DRP) can foster patient safety.¹ However, the benefit of this service in the new setting of a computerised physician order entry (CPOE) system with a clinical decision support system (CDSS) is unknown.

Aim and objectives The aim of the study was to evaluate a RPCS on wards with CPOE-CDSS, its need in general and its effectiveness on prescription changes and thereby on patient safety.

Material and methods Over a period of 3 months (February–April 2021), patients with eGFR_absolute/KreaCl <60 mL/min of one surgical and one orthopedic ward at a German University Hospital received a medication review for DRP by a renal pharmacist for all medication presented in the CPOE-CDSS Meona during weekdays. Written consultations explaining DRP and recommending interventions to solve them (eg, dose or drug adaptation) were presented to physicians directly in the drug chart tab of the CPOE-system. The prescription changes were retrospectively evaluated. Ethical approval was obtained from the ethics committee at LMU Munich (registration number 21–0743).

Results During 53 working days, 712 (30.5%) of 2331 screened patients were included with an eGFR_absolute/KreaCl <60 mL/min and a pharmacist-led medication review was performed for all medication presented in the CPOE-system (Meona). In 79/712 (11.1%) patients one or more DRP were detected (median 1 DRP (1–3) per patient) and written recommendations were shared via Meona. In total, 104 DRP were identified, mostly caused by ‘dosage too high’ (n=55; 52.9%), ‘dosage regime wrong’ (n=13; 12.5%) and ‘contraindication’ (n=9; 8.7%). Acceptance rate of recommendations was 74.0% (n=77/104). In 9 cases (8.7%) the recommendation was consciously retained after discussion because of lack of alternatives, in 11 (10.6%) the prescription remained unchanged for unknown reasons and in 7 (6.7%) the result was unknown due to discharge.

Conclusion and relevance The pharmacist-led medication reviews identified DRP in patients with RI even in the setting of prescribing in a CPOE-CDSS. A RPCS in this setting successfully increased appropriate prescribing by physicians and thus improved patient safety.

References and/or acknowledgements 1. Seiberth S, et al. Implementation of a renal pharmacist consultant service – information sharing in paper versus digital form. J Clin Pharm Ther 2021;46:838–845.

Conflict of interest No conflict of interest