Background: Adverse drug events (ADEs) remain a major source of preventable harm in hospital settings. Inappropriate medication regimens, such as polypharmacy, drug-drug interactions, and inappropriate dosages based on patient factors, are common risk factors associated with ADEs. Clinical decision support (CDS) tools can support pharmacists at the point of care and enhance pharmacist decision-making efficiency. Despite the potential benefits of these tools to improve medication appropriateness, implementation challenges remain. Therefore, as part of a larger pre-post mixed methods hybrid type 2 implementation effectiveness study, we evaluated the use and usability of the Synapse Medicine Platform and solicited strategies to mitigate implementation barriers and promote facilitators.
Methods: The Synapse Medicine Platform analyzes drug-related risks based on patients’ clinical characteristics and provides recommendations regarding the appropriateness of each patient’s medication regimen, including contraindications based on age and medical conditions; drug-drug interactions; and correct dosing for age, renal impairment, and hepatic impairment. The sample consisted of 10 pharmacists who rounded with inpatient general medical teams at two large academic medical centers. Pharmacists were recruited by email and in-person and were eligible if they received training and used the Synapse tool for at least one month prior to the interview. The virtual interviews lasted 45-60 minutes and were transcribed and verified for accuracy before analysis commenced. The Consolidated Framework for Implementation Research was used to develop the semi-structured interview guide and the development of an a priori codebook, which was refined during the analysis. Two researchers used a rapid qualitative analysis approach with a template to summarize each interview, followed by compiling summaries into a structured matrix for a quick comparison across participants.
Results: Pharmacists reported several positive effects/facilitators: inclusion of STOPP-START criteria for inappropriate meds in the elderly, search functionality by adverse drug reaction, and software that was easy to navigate and user-friendly. Pharmacists also reported some barriers (Table 1), including information overload (e.g., too many alerts), incomplete information (e.g., missing creatinine clearance as opposed to eGFR), and the lack of integration with the hospital’s EHR: while the tool pulled medication and clinical information from the EHR, it needed to be opened separately, and each patient’s medical record number needed to be entered.Recommended implementation strategies to mitigate barriers included improved visual displays, adding creatinine clearance to the software, integrating the CDS into the EHR system, using the CDS tool outside of hospital rounds, and providing additional training. Future implementation recommendations (Table 2) included trying it in settings with fewer pharmacists and/or with non-pharmacist clinicians; getting buy-in from stakeholders like physicians and nurses, facilitated with user testimonials; and getting support from leadership.
Conclusions: Pharmacists identified software improvements, opportunities for scale-up, and levers for accelerating adoption. A medication safety CDS tool fully integrated into the EHR and supported by stakeholders would enhance its implementation in inpatient settings.
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