Development, Validation, and Assessment of Clinical Impact of Real-time Alerts to Detect Inpatient As-Needed Opioid Orders With Duplicate Indications: Prospective Study

Abstract

Background: As-needed (PRN) opioid orders with duplicate indications can lead to medication errors and opioid-related adverse drug events.

Objective: The objective of our study was to build and validate real-time alerts that detect duplicate PRN opioid orders and assist clinicians in optimizing the safety of opioid orders.

Methods: This single-center, prospective study used an iterative, 3-step process to refine alert performance by advancing from small sample evaluations of positive predictive values (PPVs) (step 1) through intensive evaluations of accuracy (step 2) to evaluations of clinical impact (step 3). Validation cohorts were randomly sampled from eligible patients for each step.

Results: During step 1, the PPV was 100% (one-sided, 97.5% CI 70%-100%) for moderate and severe pain alerts. During step 2, duplication of 1 or more PRN opioid orders was identified for 17% (34/201; 95% CI, 12%-23%) of patients during chart review. This bundle of alerts showed 94% sensitivity (95% CI 80%-99%) and 96% specificity (95% CI 92%-98%) for identifying patients who had duplicate PRN opioid orders. During step 3, at least 1 intervention was made to the medication profile for 77% (46/60; 95% CI 64%-87%) of patients, and at least 1 inappropriate duplicate PRN opioid order was discontinued for 53% (32/60; 95% CI 40%-66%) of patients.

Conclusions: The bundle of alerts developed in this study was validated against chart review by a pharmacist and identified patients who benefited from medication safety interventions to optimize PRN opioid orders.

Keywords: as-needed opioids; automated alerts; duplicate orders; opioid stewardship; pain.