Table 1.

Summary of selected studies of drug alerts in patients with CKD and patients with AKI (43,44)

StudyTitleStudy ParticipantsDurationControlInterventionMeasure of EfficacyKey Results
Hospitalized   patients with CKD
 Chertow et al. (12)Guided medication dosing for inpatients with renal insufficiency7490 Patients in a single tertiary care hospitalFour consecutive 2-mo intervalsUsual computerized order entry systemReal time computerized decision support system for prescribing drugs in patients with renal insufficiency coupled with computerized order entry systemRates of appropriate prescription (dose, frequency), length of stay, hospital and pharmacy costs, changes in renal functionA computerized decision support system increased the number of appropriate prescriptions versus the computerized order entry system alone by both dose (67% in the intervention group versus 54% in the control group; P<0.001) and frequency (59% intervention; 35% control)
 Nash et al. (37)Reducing excessive medication administration in hospitalized adults with renal dysfunctionAdult inpatients with impaired kidney function at a 1171-bed academic medical centerBaseline data collection: 7 wk; alert (intervention) data collection: 10 wkUsual careComputerized alert system for pharmacists to identify hospitalized patients who had medications requiring dose adjustments in the setting of renal insufficiency coupled with pharmacist feedbackPercentage of medications dosed in excess in the setting of renal insufficiency that were subsequently dose adjustedDuring usual care, 23.2% of medications administered to renally impaired adult inpatients were dosed in excess compared with 16.8% after alert implementation (P<0.05)
 Galanter et al. (38)A trial of automated decision supp0ort alerts for contraindicated medications using computerized physician order entry233 Patients at a single tertiary care hospital14 mo after alert implementationHistorical cohort established for the fourth month period before alert implementationAutomated alert system built into the electronic medical record system that triggered when an order was made for a drug with a “threshold” creatinine clearance that was greater than the patient's most recently estimated creatinine clearanceProportions of patients receiving at least one dose of a contraindicated medicationIn the historical cohort, 87% of patients received at least one dose of a contraindicated drug versus 47% after alert implementation (P<0.001); in the alert group, 41% of instances in which an alert was given resulted in immediate cancellation of the order
 Bhardwaja et al. (44)Improving prescribing safety in patients with renal insufficiency in the ambulatory setting: The Drug Renal Alert Pharmacy (DRAP) program6125 Adult patients in an integrated health care system with estimated creatinine clearance of 5 ml/min or lower and not receiving dialysis15 moUsual careA computerized tool used to alert pharmacists at the time of dispensing to errors in drug selection and dosing in patients with renal insufficiencyProportion of mediation errors (target drugs that should be avoided or were inappropriately dosed)The proportion of medication errors in the alert group (33%) was significantly lower than that for the control group (49%; P<0.001)
 Terrell et al. (43)Computerized decision support for medication dosing in renal insufficiency: A randomized, controlled trial42 Physicians in an academic emergency department randomized to either intervention or control group2 yrUsual careA decision support system that provided dosing recommendations for targeted medication in adult patients with renal insufficiency being discharged and displayed when the patient’s estimated creatinine clearance was belowProportion of targeted medications that were excessively dosed among all prescriptions for the targeted population of patientsPhysicians in the control group had a larger occurrence of excessively dosing of medications (74% of prescriptions) compared with the control group (43%)
Hospitalized patients  at risk of AKI
 Goldstein et al. (39)A sustained quality improvement program reduces nephrotoxic medication-associated acute kidney injury1749 Noncritically ill hospitalized children in a quaternary pediatric inpatient hospital receiving intravenous aminoglycoside or more than three nephrotoxins3 yr, 7 moProspective study with no controlAutomated system to identify patients exposed to nephrotoxins in near real time and recommend more frequent creatinine measurementNephrotoxic medication exposure, AKI ratesAfter implementation, the rate of exposure to nephrotoxic medications decreased by 38%, and the rate of AKI decreased by 64%
Hospitalized patients  with AKI
 McCoy et al. (41)A computerized provider order entry intervention for medication safety during acute kidney injury: A quality improvement report1598 Adult inpatients in an academic tertiary care facility with a minimum 0.5-mg/dl increase in serum creatinine over 48 h after an order of one of 122 nephrotoxins or medications excreted by the kidneys1 yr, 8 moUsual care before alert implementation (717 patients)(1) A passive popup alert that displayed for patients with a 0.5-mg/dl increase in serum creatinine and prescribed a targeted medication; (2) an interruptive alert appearing when providers tried to exit from an ordering session without adjusting medication as suggested by the passive alert as required a provider actionDiscontinuation or modification of a target medication within 24 h of alert; time to discontinuation or modificationIn response to the interruptive alert, medication discontinuation/modification improved from 35.2% preintervention to 52.6% postintervention (P<0.001); rates of this modification were significantly faster than those preintervention (P<0.001)
 Roberts et al. (42)Clinical decision support implemented with academic detailing improves prescribing of key renally cleared drugs in the hospital setting300-Bed teaching hospital5 moUsual care 6 mo before alert implementationAn automated system that calculated and updated renal function and doses of key drugs adjusted for renal function; academic detailing incorporated a 15-min session with clinicians on how to navigate the programRate of dosing conformity and management for key renally cleared drugs in hospitalized patientsDosing conformity improved for enoxaparin (from 68% to 86%; P=0.03), gentamicin (from 63% to 87%; P=0.01), and vancomycin (from 47% to 77%; P=0.07); during episodes of acute renal impairment, renally cleared medications were held in 62% of cases in patients during the intervention period versus 38% of cases in patients in the preintervention period