title: Development, implementation and outcome analysis of semi-automated alerts for metformin dose adjustment in hospitalized patients with renal impairment.
abstract: Overdosing of the oral antidiabetic metformin in impaired renal function is an important contributory cause to life-threatening lactic acidosis. The presented project aimed to quantify and prevent this avoidable medication error in clinical practice.
  
  
  
  We developed and implemented an algorithm into a hospital's clinical information system that prospectively identifies metformin prescriptions if the estimated glomerular filtration rate is below 60 mL/min. Resulting real-time electronic alerts are sent to clinical pharmacologists and pharmacists, who validate cases in electronic medical records and contact prescribing physicians with recommendations if necessary.
  
  
  
  The screening algorithm has been used in routine clinical practice for 3 years and generated 2145 automated alerts (about 2 per day). Validated expert recommendations regarding metformin therapy, i.e., dose reduction or stop, were issued for 381 patients (about 3 per week). Follow-up was available for 257 cases, and prescribers' compliance with recommendations was 79%. Furthermore, during 3 years, we identified eight local cases of lactic acidosis associated with metformin therapy in renal impairment that could not be prevented, e.g., because metformin overdosing had occurred before hospitalization.
  
  
  
  Automated sensitive screening followed by specific expert evaluation and personal recommendations can prevent metformin overdosing in renal impairment with high efficiency and efficacy. Repeated cases of metformin-associated lactic acidosis in renal impairment underline the clinical relevance of this medication error. Our locally developed and customized alert system is a successful proof of concept for a proactive clinical drug safety program that is now expanded to other clinically and economically relevant medication errors. Copyright © 2016 John Wiley & Sons, Ltd.
authors.affiliation: Department of Clinical Pharmacology and Toxicology, University Hospital Zurich, Zurich, Switzerland.|Swiss Federal Institute of Technology Zurich (ETHZ), Zurich, Switzerland.
authors.forename: David
authors.initials: D
authors.lastname: Niedrig
authors.affiliation: Department of Clinical Pharmacology and Toxicology, University Hospital Zurich, Zurich, Switzerland.
authors.forename: Regina
authors.initials: R
authors.lastname: Krattinger
authors.affiliation: Department of Clinical Pharmacology and Toxicology, University Hospital Zurich, Zurich, Switzerland.
authors.forename: Annika
authors.initials: A
authors.lastname: Jödicke
authors.affiliation: Department of Clinical Pharmacology and Toxicology, University Hospital Zurich, Zurich, Switzerland.
authors.forename: Carmen
authors.initials: C
authors.lastname: Gött
authors.affiliation: Department of Medical Informatics, University Hospital Zurich, Zurich, Switzerland.
authors.forename: Guido
authors.initials: G
authors.lastname: Bucklar
authors.affiliation: Department of Clinical Pharmacology and Toxicology, University Hospital Zurich, Zurich, Switzerland. russmann@drugsafety.ch.|Swiss Federal Institute of Technology Zurich (ETHZ), Zurich, Switzerland. russmann@drugsafety.ch.|drugsafety.ch, Küsnacht, ZH, Switzerland. russmann@drugsafety.ch.|Zurich Center for Integrative Human Physiology (ZIHP), Zurich, Switzerland. russmann@drugsafety.ch.
authors.forename: Stefan
authors.initials: S
authors.lastname: Russmann
mesh_terms: D000140:Acidosis, Lactic / Q000139:chemically induced / Q000517:prevention & control; D000368:Aged; D000465:Algorithms; D001331:Automation; D004305:Dose-Response Relationship, Drug; D062787:Drug Overdose / Q000517:prevention & control; D005260:Female; D005500:Follow-Up Studies; D005919:Glomerular Filtration Rate; D006751:Hospital Information Systems; D006801:Humans; D007004:Hypoglycemic Agents / Q000008:administration & dosage* / Q000009:adverse effects; D008297:Male; D050316:Medical Order Entry Systems; D008508:Medication Errors / Q000517:prevention & control; D008687:Metformin / Q000008:administration & dosage* / Q000009:adverse effects; D008875:Middle Aged; D010595:Pharmacists / Q000458:organization & administration; D024382:Professional Role; D051437:Renal Insufficiency / Q000503:physiopathology*
chemical_list: D007004:Hypoglycemic Agents; D008687:Metformin
keywords: clinical decision support; drug safety; interventional pharmacoepidemiology; metformin; pharmacoepidemiology; renal impairment