Department of Medicine Quality Improvement

Decision Support Systems: Medication Safety


Matthew Berger 

Eran Bellin, MD 

Jeffrey Weiss, MD 

Jason Adelman, MD 


Image: Medication dosage reminders are a key function of Montefiore's decision support systems. full image 

The spectrum of medical care is too complex for any one doctor to fully understand. Medical decision support systems (MDSS), a class of knowledge-based software applications, are increasingly assisting physicians in making cliniclal decisions. Commonly used to support particular diagnostic or therapeutic tasks, MDSS potentially help doctors organize, store, and apply medical knowledge; improve speed and accuracy of diagnoses and treatments; and improve patient outcomes by avoiding errors due to insufficient knowledge.

Decision support applications, most of which were conceived and developed by the Department of Medicine, have been implemented throughout Montefiore Medical Center. A grant has been secured to refine and improve these systems. Specific efforts include targeting decision support to parallel with patient care in real time, and creating intelligent, population-specific alert systems that effectively assist physicians.

Narcotics Dosing Advisory 

Appropriate narcotics dosages vary greatly from patient to patient, and are influenced by variables including type of drug, type of pain, associated risks, and the patient’s age and condition.

A recent decision support application was targetted to lessen the number of incorrect dosing instances. When narcotics orders are entered, the system checks the patient records for previous usage and recommends appropriate doses based on this information. In addition, the system alerts the physician and provides dosage tables when orders exceed 150% of previously ordered doses, gives conversion tables to assist with appropriate dosage selection of equivalent narcotics, and recommends starting doses for patients with no prior narcotics histories.

Medication Dosage Advisory and Barcode Charting 

Thousands of deaths each year are caused by medication errors in hospitals nationwide. Two support applications have been put in place to reduce the number of errors made by Montefiore physicians and nurses.

  1. The first, a medication dosage advisory tool, provides patient-specific results and recommendations. The tool improves medication safety by alerting the physician when a dosage ceiling has been reached, and requiring a consultation with a pharmacist before the order is cleared. The medication dosage advisory application has resulted in a threefold reduction of medication orders exceeding the maximum dosage.
  2. With fewer errors made at the time of prescribing, barcode charting, a system through which nurses check the identification of a patient by comparing barcodes on the patient's bracelet and chart, provides a safeguard at the time of medication administration (the last stage in the cycle and a likely place for errors to occur). Barcode charting helps prevent medication errors by alerting the nurse of discrepancies in patient, drug, dose, or time. Since its implementation, this tool has prevented an average of one patient per day from receiving the wrong medication.

Hematology Applications 

  1. Gradual and subtle decreases in platelet count may impede timely recognition of heparin-induced thrombocytopenia (HIT), a rare but often deadly complication. A clinical decision support tool has been put in place to alert physician in cases of at-risk patients. When patient with heparin orders experience decreases in platelet count consistent with HIT, the physician is alerted to order a hematology consult. Since this tool was implemented, every potential HIT case has been detected and addressed.
  2. Hospitalized patients with decreased mobility are known to be at increased risk for developing deep vein thrombosis (DVT).  The computer ordering system at Montefiore Medical Center provides clinicians evidence-based guidelines to prevent DVTs when a patient is admitted to the hospital, and allows them to select from a list of prevention strategies based on the patient’s history and coagulation status. This initiative uses information gathered from research conducted to advise and support practicing physicians in the judicious use of oral anticoagulants.
  3. Too many blood transfusions can lead to complications including hemochromatosis (iron overload) and alloimmunization (immunity to donor blood). Upon entry of a transfusion order, Montefiore's decision support system scans patients' records for blood hemoglobin levels and alerts the physician if that patient is above the transfusion threshold. The physician is also notified if a patient's religious or other practices indicate an objection to accepting blood.

Procedure Notation Reminders 

High patient volumes and overstressed acute care situations can cause clinical documentation to suffer. Missing documentation can decrease Medicaid and Medicare reimbursement, and complete and timely medical documentation may improve patient safety and reduce medical liability risks.

Automated electronic reminders have been shown to improve minor procedure documentation compliance. Montefiore Medical Center has implemented documentation reminders for numerous routine medical procedures.


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