Task force wants DUR 'hard stop' alert


A task force on drug use review software systems favors a hard stop edit on high risk drug interactions.



Task force wants DUR 'hard stop' alert

A task force investigating ways to improve on current on-line drug use review (DUR) software systems is pushing for a hard stop on high-risk drug interaction alerts as a way to protect patients by reducing medication errors.

Helping the pharmacist tell the difference between potentially serious drug-drug interactions (DDIs) and annoying, lower-grade alerts is the reason an on-line prospective DUR (OPDUR) task force has been created by the Academy of Managed Care Pharmacy and the United States Pharmacopoeia.

A task force steering committee includes the American Society for Automation in Pharmacy, the American Pharmaceutical Association, the Food & Drug Administration, the National Association of Chain Drug Stores, the National Community Pharmacists Association, and the Pharmaceutical Care Management Association (PCMA).

Backed by a grant from Janssen Pharmaceutica, the task force's goal is to help reduce the "noise" created by the flood of alerts pouring out of OPDUR systems that lead many pharmacists to simply ignore messages as insignificant or irrelevant.

The task force sponsors want to institute a so-called dead stop or hard edit field in OPDUR programs that would be triggered only by serious DDIs. The hard edit would freeze the computer until the pharmacist had documented an intervention and sent a message back to the third party that the intervention had occurred. Only then could the prescription be dispensed.

"What we're trying to do is establish a kind of top-tier list of drug-drug interactions that meet specific criteria for serious harm," said Richard Fry, R.Ph., AMCP's senior director of pharmacy affairs. "And those criteria will be developed based on the best available evidence from the USP Therapeutic Decision Making Expert Committee. "We're not making the rash statement that pharmacists intentionally ignore alerts, but we want to institute a system that they can't ignore."

Giving the pharmacist a way to indicate that a serious DDI has already been resolved is a necessary feature of any new system, Fry said. For example, the same DDI alert may pop up every time a patient's Rx is refilled. In addition, many systems currently don't know when a drug has been changed or discontinued. "Prescriptions aren't properly aged, and there's no mechanism to say that drug B has replaced drug A and then eliminate it from the system," he said. "So pharmacists continually get alerts on drugs that the patient hasn't taken for six months. That just contributes to the noise."

Well aware of community pharmacy's current Rx crunch and manpower problems, AMCP is sensitive to the need to reassure harassed pharmacists that any system of hard edits will be carefully constructed. "The last thing we want to do is impact the workload of the pharmacist," Fry said. "We're very sensitive to the fact that anything we do like this may impact workload. But this is going to give pharmacists a considerable amount of reassurance that, at least for a given subset of interactions, they can be confident that these are the alerts they need to take extremely seriously based on the best available evidence. The real bottom line is to help them prevent medication errors."

There is reason for concern about DUR programs currently being used, according to research conducted by faculty at the University of Washington School of Pharmacy. The study included 516 Washington State chain and health maintenance organization pharmacies that were using nine different drug-drug interaction software programs. When presented with 16 well-established DDIs contained in six fictitious patient profiles, the systems failed to detect those DDIs one-third of the time.

The AMCP-USP effort has a much narrower focus than another DUR task force recently put together by PCMA and APhA (Drug Topics, Jan. 15). The PCMA-APhA group has the broader mission of finding ways to reduce medication errors through electronic prescribing and unit-of-use drug packaging, as well as improved DUR systems.

To make DUR dead stops workable in community pharmacy's real world of high prescription volume and high stress, the AMCP-USP initiative will:

• Establish evidence-based, clinically significant criteria for use by health professionals and OPDUR vendors for classifying DDIs with a high probability of causing serious patient harm.

• Forge a consensus on which interactions meet the above criteria for causing serious harm.

• Set up a mechanism for ongoing review of DDIs to permit the addition or deletion of individual drugs and drug classes.

• Facilitate collaboration between health-care providers and on-line vendors to ensure that the specified DDIs are integrated into the DUR components used at the point of care.

Carol Ukens


Carol Ukens. Task force wants DUR 'hard stop' alert.

Drug Topics


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