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Failure to adjust the dosage of medications for patients' renal function is an important cause of adverse drug events, and may cause subclinical issues as well. In part because of the enormous number of medications involved and the time it takes to perform calculations, physicians frequently do not account for renal insufficiency when choosing a medication or dose. While pharmacists sometimes intercept such errors, many are missed. Automated decision aids that suggest an adjusted dose or alternate agent based on an estimated creatinine clearance can improve physician compliance with recommended practices and may ultimately reduce drug-related injuries. Current implementation and evaluation of several decision support software packages that address patients with renal insufficiency are reviewed.
Accurate drug dosing and appropriate drug selection are key goals in the effort to reduce the frequency of adverse drug events. Among the many patient characteristics that can modify a standard drug dose or change the recommended class of agent, renal insufficiency is the most common. Forty percent of patients admitted to Brigham and Women's Hospital in Boston, Massachusetts, have baseline renal insufficiency, and several studies have demonstrated that acute renal failure during hospital stays is common. Additionally, renally excreted or nephrotoxic medications constitute 20% of all medications in our current hospital formulary, and are potentially harmful if not adjusted during renal dysfunction.
Previous studies have documented that physicians often do not adjust medications in the setting of renal insufficiency, and that this behavior can lead to patient injury and increased resource utilization. These adverse events are often preventable because the accumulation of a renally cleared drug is predictable in a patient with renal insufficiency. In an analysis of adverse drug events in hospitalized patients, guided dose algorithms (including adjustment for renal insufficiency) could have prevented 6% of all adverse events.
For many years, clinical pharmacists in the hospital setting have been assigned the task of reviewing medication orders in patients with renal insufficiency for inappropriate dosing. While beneficial, such review is labor-intensive, and requires collecting patient data, calculating a creatinine clearance (CrCl) level, and contacting a physician to change the order if necessary. With the advent of computerized physician order entry, it is possible to intervene at the point of ordering to increase the likelihood of accurate medication selection and dosing of medications based on an estimated glomerular filtration rate. Intervening at the point of order entry more reliably intercepts potential adverse events than the frequent activation of downstream safety systems. Pharmacists can then focus their efforts on more complex patients such as those in the ICU and on transplant wards.
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