Title: Impact of a System-wide Pharmacy Clinical Decision Support Council on Pharmacist-Facing Medication Warning Alerts Authors: Benny Zhang, PharmD; Craig MacDonald, PharmD
Background: Clinical decision support (CDS) is a powerful tool that provides clinicians with knowledge and patient-specific information, filtered or presented at appropriate times, to ensure safe and effective patient care. Medication warning alerts can support clinical decision-making, reduce medication errors and adverse drug events, and improve adherence to evidence-based practice. However, redundant or inappropriate medication warning alerts can lead to alert fatigue and result in unintended consequences that may compromise the safety and quality of patient care. In our system, medication warnings are supplied by a third-party vendor and can appear during order entry, verification, or medication administration and impact providers, pharmacists, and nurses. The formation of a system-wide pharmacy clinical decision support council aimed to optimize medication-related alerts to ensure front-end clinicians are seeing relevant and important warnings across a large health-system. The purpose of this study is to evaluate the impact of a system-wide pharmacy clinical decision support council on the volume of pharmacist-facing medication warning alerts.
Methods: This was a retrospective pre-post analysis conducted using EHR extracted data from 2023 to 2026 in a single health-system. Medication warning alerts presented to pharmacists were evaluated. Trends in alert volume (per 1,000 orders) were analyzed over time to assess changes following decisions made by the pharmacy clinical decision support council.
