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E-prescribing system alerts doctors when VTE prophylaxis not offered

A group of hospitals in Boston, Massachusetts, has reduced theincidence of venous thromboembolism (VTE) among its patients throughprescriber alerts generated by its electronic prescribing system.Thomas Cooley, assistant director of pharmacy services at the hospital(Brigham and Women’s Hospital) presented the group’s findings at the2009 joint conference of the Guild of Healthcare Pharmacists and theUnited Kingdom Clinical Pharmacy Association, held in Leicester, on15–17 May 2009

By Gareth Malson, MRPharmS

A group of hospitals in Boston, Massachusetts, has reduced the incidence of venous thromboembolism (VTE) among its patients through prescriber alerts generated by its electronic prescribing system.

Thomas Cooley, assistant director of pharmacy services at the hospital (Brigham and Women’s Hospital) presented the group’s findings at the 2009 joint conference of the Guild of Healthcare Pharmacists and the United Kingdom Clinical Pharmacy Association, held in Leicester, on 15–17 May 2009.

The hospital’s e-prescribing system’s “events engine” (see Box) has been developed to identify patients who are at greater risk of developing a VTE. Risk factors for VTE have been assigned an risk rating (eg, cancer = 3, previous VTE = 3, major surgery = 2, body mass index above 30 = 1). The engine assigns every patient a total VTE risk score by accumulating these ratings.

Events engine

In 1995, Brigham and Women’s Hospital in Boston, Massachusetts, developed a bespoke electronic prescribing system that included software to identify potential adverse drug events. This “events engine” constantly monitors hospital laboratory results alongside all prescribed medicines to identify potential adverse drug reactions.

The system incorporates “rules” that generate an alert when they are broken. For example, an alert would be generated if a patient’s platelet count has fallen by more than 50% in 10 days while he or she is being treated with heparin.

Every morning, pharmacists are given a list of possible events that have occurred for inpatients on their wards. At that point, the pharmacist becomes responsible for following up these events during the day.

The pharmacists must determine whether an intervention is necessary and contact the appropriate member of medical staff. They must also document every suggested intervention on the prescribing system and record whether or not the medical staff followed their advice.

The system currently incorporates about 75 rules, although these are constantly being reviewed to limit the number of alerts generated for events that do not require intervention. He added that, in 2008, 2,050 alerts resulted in a pharmacist suggesting an intervention, of which around 85% were accepted by medical staff.

If a patient’s total score is above 4, the patient’s doctor is alerted when he or she “logs on” to the system and accesses the patient’s prescribing record. The alert advises the doctor to prescribe mechanical or pharmacological VTE prophylaxis (if it has not been prescribed already).

In a study conducted by the trust, implementation of the alert system decreased the incidence of VTE by 41%. However, the study also revealed that only about 33% of alerts resulted in prophylaxis being prescribed.

Mr Cooley explained that, consequently, the alert messages have been modified. Rather than a single screen alert suggesting that prophylaxis be prescribed, the system now displays three consecutive alert screens:

  • The first screen is the same as before, however it now includes an intranet hyperlink that allows the prescriber to view the published evidence for prescribing thromboprophylaxis
  • If the doctor opts not to prescribe thromboprophylaxis, a second screen appears, which requires the doctor to specify his or her reason for not doing so
  • If thromboprophylaxis is still not prescribed, the third screen points out that there is no increased risk of bleeding from using mechanical prophylaxis. Prescribers are again offered the opportunity to order compression stockings, for example, and are required to “opt out” to avoid doing so


Mr Cooley confirmed that a further study is being conducted to determine whether the updated alert system had resulted in a further increase in the use of VTE prophylaxis or a further reduction in the incidence of VTE.

Mr Cooley concluded that the key to improving medication safety involved making medication errors easy to track, difficult to make and easy to monitor. He added that pharmacists could be the “bulldogs” for implementing a hospital’s patient safety agenda.

Citation: Clinical Pharmacist URI: 10965950

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  • Tom Cooley believes pharmacists can be the “bulldogs” of patient safety

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