Use of Computerized Physician Order Entry with Clinical Decision Support to Prevent Dose Errors in Pediatric Medication Orders: A Systematic Review

BACKGROUND

Prescribing is a high-risk task within the pediatric medication-use process and requires defenses to prevent errors. Such system-centric defenses include electronic health record systems with computerized physician order entry (CPOE) and clinical decision support (CDS) tools that assist safe prescribing. The objective of this study was to examine the effects of CPOE systems with CDS functions in preventing dose errors in pediatric medication orders.

MATERIAL AND METHODS

This study followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) 2020 criteria and Synthesis Without Meta-Analysis (SWiM) items. The study protocol was registered in PROSPERO (CRD42021277413). The final literature search on MEDLINE (Ovid), Scopus, Web of Science, and EMB Reviews was conducted on 10 September 2023. Only peer-reviewed studies considering both CPOE and CDS systems in pediatric inpatient or outpatient settings were included. Study selection, data extraction, and evidence quality assessment (JBI critical appraisal tool assessment and GRADE approach) were carried out by two individual reviewers. Vote counting method was used to evaluate the effects of CPOE-CDS systems on dose errors rates.

RESULTS

A total of 17 studies published in 2007-2021 met the inclusion criteria. The most used CDS tools were dose range check (n = 14), dose calculator (n = 8), and dosing frequency check (n = 8). Alerts were recorded in 15 studies. A statistically significant reduction in dose errors was found in eight studies, whereas an increase of dose errors was not reported.

CONCLUSIONS

The CPOE-CDS systems have the potential to reduce pediatric dose errors. Most beneficial interventions seem to be system customization, implementing CDS alerts, and the use of dose range check. While human factors are still present within the medication use process, further studies and development activities are needed to optimize the usability of CPOE-CDS systems.

Measurement of Ambulatory Medication Errors in Children: A Scoping Review

BACKGROUND AND OBJECTIVES

Children use most medications in the ambulatory setting where errors are infrequently intercepted. There is currently no established measure set for ambulatory pediatric medication errors. We have sought to identify the range of existing measures of ambulatory pediatric medication errors, describe the data sources for error measurement, and describe their reliability.

METHODS

We performed a scoping review of the literature published since 1986 using PubMed, CINAHL, PsycINFO, Web of Science, Embase, and Cochrane and of grey literature. Studies were included if they measured ambulatory, including home, medication errors in children 0 to 26 years. Measures were grouped by phase of the medication use pathway and thematically by measure type.

RESULTS

We included 138 published studies and 4 studies from the grey literature and identified 21 measures of medication errors along the medication use pathway. Most measures addressed errors in medication prescribing (n = 6), and administration at home (n = 4), often using prescription-level data and observation, respectively. Measures assessing errors at multiple phases of the medication use pathway (n = 3) frequently used error reporting databases and prospective measurement through direct in-home observation. We identified few measures of dispensing and monitoring errors. Only 31 studies used measurement methods that included an assessment of reliability.

CONCLUSIONS

Although most available, reliable measures are too resource and time-intensive to assess errors at the health system or population level, we were able to identify some measures that may be adopted for continuous measurement and quality improvement.

Harnessing the Electronic Health Record to Distribute Transition Services to Adolescents With Inflammatory Bowel Disease

OBJECTIVES

The aim of the study was to evaluate feasibility and utility of an electronic health record (EHR) activity to assess transitional readiness, deliver services to meet individual needs, and to track patient progress.

METHODS

We developed a Transition EHR activity (TEA) to track patients through a standardized process where transition readiness is annually assessed and services distributed based on need. The process assesses transition skills starting at age 12 years and sets goals through shared decision-making, delivers resources according to need, reviews patients' personal medical histories, and documents healthcare transfer to adult gastroenterology. We piloted TEA among patients with inflammatory bowel disease (IBD) ages ≥12 years. Distribution to patients was measured and tolerability assessed via patient self-report evaluations.

RESULTS

Since launch, TEA has been distributed to all eligible patients (N = 53) with a median age of 16 (14,18) years (median [IQR]), 62% male, 58% white, 26% Hispanic at our weekly dedicated IBD clinic. All have performed the transition skills' self-assessment and practicum, and set transition goals with their healthcare provider. Of these individuals, 41 (77%) participated in survey feedback. On a utility rating scale of 0 (not helpful at all) to 10 (very helpful), patients reported median (IQR) utility scores of 8 (7,10) for the transition readiness assessment, 9 (7,10) for transition resources provided, and 9 (7,10) for the medical history summary. Most (91%) would recommend TEA to other patients.

CONCLUSIONS

TEA standardized delivery of resources among pediatric IBD patients and was well received and friendly to clinical workflow.

Use of a Web-Based Calculator and a Structured Report Generator to Improve Efficiency, Accuracy, and Consistency of Radiology Reporting

While medical calculators are common, they are infrequently used in the day-to-day radiology practice. We hypothesized that a calculator coupled with a structured report generator would decrease the time required to interpret and dictate a study in addition to decreasing the number of errors in interpretation. A web-based application was created to help radiologists calculate leg-length discrepancies. A time motion study was performed to evaluate if the calculator helped to decrease the time for interpretation and dictation of leg-length radiographs. Two radiologists each evaluated two sets of ten radiographs, one set using the traditional pen and paper method and the other set using the calculator. The time to interpret each study and the time to dictate each study were recorded. In addition, each calculation was checked for errors. When comparing the two methods of calculating the leg lengths, the manual method was significantly slower than the calculator for all time points measured: the mean time to calculate the leg-length discrepancy (131.8 vs. 59.7 s; p < 0.001), the mean time to dictate the report (31.8 vs. 11 s; p < 0.001), and the mean total time (163.7 vs. 70.7 s; p < 0.001). Reports created by the calculator were more accurate than reports created via the manual method (100 vs. 90%), although this result was not significant (p = 0.16). A calculator with a structured report generator significantly improved the time required to calculate and dictate leg-length discrepancy studies.

Factors contributing to medication errors made when using computerized order entry in pediatrics: a systematic review

OBJECTIVE

To identify and understand the factors that contribute to medication errors associated with the use of computerized provider order entry (CPOE) in pediatrics and provide recommendations on how CPOE systems could be improved.

MATERIALS AND METHODS

We conducted a systematic literature review across 3 large databases: the Cumulative Index to Nursing and Allied Health Literature, Embase, and Medline. Three independent reviewers screened the titles, and 2 authors then independently reviewed all abstracts and full texts, with 1 author acting as a constant across all publications. Data were extracted onto a customized data extraction sheet, and a narrative synthesis of all eligible studies was undertaken.

RESULTS

A total of 47 articles were included in this review. We identified 5 factors that contributed to errors with the use of a CPOE system: (1) lack of drug dosing alerts, which failed to detect calculation errors; (2) generation of inappropriate dosing alerts, such as warnings based on incorrect drug indications; (3) inappropriate drug duplication alerts, as a result of the system failing to consider factors such as the route of administration; (4) dropdown menu selection errors; and (5) system design issues, such as a lack of suitable dosing options for a particular drug.

DISCUSSION AND CONCLUSIONS

This review highlights 5 key factors that contributed to the occurrence of CPOE-related medication errors in pediatrics. Dosing support is the most important. More advanced clinical decision support that can suggest doses based on the drug indication is needed.

Pediatricians' Understanding and Experiences of an Electronic Clinical-Decision-Support-System

Objectives

Subsequent dosing errors after implementing an Electronic Medical Record (EMR) at a pediatric hospital in Sweden led to the development, in close collaboration with the clinical profession, of a Clinical Decision Support System (CDSS) with Dose Range Check and Weight Based Dose Calculation integrated directly in the EMR. The aim of this study was to explore the understanding and experiences of the CDSS among Swedish pediatricians after one year of practice.

Methods

Semi-structured interviews with physicians at different levels of the health care system were performed with seventeen pediatricians working at three different pediatrics wards in Stockholm County Council. The interviews were analysed with a thematic analysis without pre-determined categories.

Results

Six categories and fourteen subcategories emerged from the analysis. The categories included the use, the benefit, the confidence, the situations of disregards, the misgivings/risks and finally the development potential of the implemented CDSS with Weight Based Dose Calculation and Dose Range Check.

Conclusions

A need for CDSS in the prescribing for children is evident to support the prevention of medication errors. After implementing a CDSS, organized efforts are crucial to understand the need for further development based on the practical knowledge of the clinical profession. Different contextual settings of health care organisations do affect the way how physicians think and act in work. When implementing a CDSS in practice we need to describe and analyse the context where the CDSS should be used as well as the prescribers’ needs in work.

Case Not Closed: Prescription Errors 12 Years after Computerized Physician Order Entry Implementation

OBJECTIVE

To assess the prolonged impact of computerized physician order entry (CPOE) on medication prescription errors in pediatric intensive care patients.

STUDY DESIGN

This observational study was conducted at a pediatric intensive care unit in which a CPOE (Metavision, iMDsoft, Israel) with a limited clinical decision support system was implemented between 2004 and 2007. Since then, no changes were made to the systems. We analyzed 2500 electronic prescriptions (1250 prescriptions from 2015 and 1250 prescriptions from 2016). Prescription errors were identified by a pediatric intensive care physician and classified as potential adverse drug events, medication prescription errors, or rule violations. Their prevalence was compared with the rate in 2007, reported in a previous study from the same unit. A randomly selected 10% of the prescriptions were also analyzed by the pediatric intensive care unit pharmacist, and the level of agreement was determined.

RESULTS

The rate of prescription errors increased from 1.4% in 2007 to 3.2% in 2015 (P = .03). Following revision of the clinical decision support system tools, prescription errors decreased to 1% in 2016 (P < .0001). The potential adverse drug event rate dropped from 2% in 2015 to 0.7% in 2016 (P = .006), and the medication prescription error rate, from 1% to 0.2% (P = .01). The agreement between the 2 reviewers was excellent (k = 0.96).

CONCLUSIONS

The rate of prescription errors may increase with time from implementation of a CPOE. Repeated surveillance of prescription errors is highly advised to plan strategies to reduce them. This approach should be considered in quality improvement of computerized information systems in general.

Implementing a Distraction-Free Practice With the Red Zone Medication Safety Initiative

BACKGROUND

The incidence of medication errors remains a continued concern across the spectrum of health care. Approaches to averting medication errors and implementing a culture of safety are key areas of focus for most institutions. We describe our experience of implementing a distraction-free medication safety practice across a large free-standing children's hospital.

METHODS

A nurse-led interprofessional group was convened to develop a program-wide quality improvement process for the practice of medication safety. A key driver diagram was developed to guide the Red Zone Medication Safety initiative. Change acceleration process was used to evaluate the implementation and impact of the initiative.

RESULTS

Since implementation in 2010, there has been a significant reduction in medication events of 79.2% (P = .00184) and 65.3% (P = .035) (in the cardiac intensive care unit and acute care cardiac unit, respectively), including months with unprecedented zero reportable medication events. There also has been a sustained decrease in the number of events reaching the patient (33.3% in the cardiac intensive care unit and 57.1% in the acute care cardiac unit).

CONCLUSIONS

The implementation of a distraction-free practice was found to be feasible and effective, demonstrating a sustained decrease in the overall number of medication events, event rate, and number of events reaching patients. This interprofessional approach was successful in a large inpatient cardiovascular program and then effectively transferred across all hospital inpatient units. Additional sites of implementation include other high-risk patient care areas such as procedure/operative units.

Meaningful Use of Electronic Health Records: Experiences From the Field and Future Opportunities

Background

With the aim of improving health care processes through health information technology (HIT), the US government has promulgated requirements for “meaningful use” (MU) of electronic health records (EHRs) as a condition for providers receiving financial incentives for the adoption and use of these systems. Considerable uncertainty remains about the impact of these requirements on the effective application of EHR systems.

Objective

The Agency for Healthcare Research and Quality (AHRQ)-sponsored Centers for Education and Research in Therapeutics (CERTs) critically examined the impact of the MU policy relating to the use of medications and jointly developed recommendations to help inform future HIT policy.

Methods

We gathered perspectives from a wide range of stakeholders (N=35) who had experience with MU requirements, including academicians, practitioners, and policy makers from different health care organizations including and beyond the CERTs. Specific issues and recommendations were discussed and agreed on as a group.

Results

Stakeholders’ knowledge and experiences from implementing MU requirements fell into 6 domains: (1) accuracy of medication lists and medication reconciliation, (2) problem list accuracy and the shift in HIT priorities, (3) accuracy of allergy lists and allergy-related standards development, (4) support of safer and effective prescribing for children, (5) considerations for rural communities, and (6) general issues with achieving MU. Standards are needed to better facilitate the exchange of data elements between health care settings. Several organizations felt that their preoccupation with fulfilling MU requirements stifled innovation. Greater emphasis should be placed on local HIT configurations that better address population health care needs.

Conclusions

Although MU has stimulated adoption of EHRs, its effects on quality and safety remain uncertain. Stakeholders felt that MU requirements should be more flexible and recognize that integrated models may achieve information-sharing goals in alternate ways. Future certification rules and requirements should enhance EHR functionalities critical for safer prescribing of medications in children.

[Impact on the improvement of paediatric emergency services using a standardised model for the declaration and analysis of incidents]

INTRODUCTION

The aim of this study is to analyse changes in the incidents reported after the implementation of a new model, and study its results on patient safety.

PATIENTS AND METHODS

In 2012 an observational study with prospective collection of incidents reported between 2007 and 2011 was conducted. In May 2012 a model change was made in order to increase the number of reports, analyse their causes, and improve the feedback to the service. Professional safety representatives were assigned to every department, information and diffusion sessions were held, and a new incident reporting system was implemented. With the new model, a new observational study with prospective collection of the reports during one year was initiated, and the results compared between models.

RESULTS

In 2011, only 19 incidents were reported in the Emergency Department, and between June 1, 2012 to June 1, 2013, 106 incidents (5.6 times more). The incidents reported were medication incidents (57%), identification (26%), and procedures (7%). The most frequent causes were human (70.7%), lack of training (22.6%), and working conditions (15.1%). Some measures were implemented as a result of these incidents: a surgical checklist, unit doses of salbutamol, tables of weight-standardised doses of drugs for cardiopulmonary resuscitation.

CONCLUSIONS

The new model of reporting incidents has enhanced the reports and has allowed improvements and the implementation of preventive measures, increasing the patient safety in the Emergency Department.

Interventions to reduce pediatric medication errors: a systematic review

BACKGROUND AND OBJECTIVE

Medication errors cause appreciable morbidity and mortality in children. The objective was to determine the effectiveness of interventions to reduce pediatric medication errors, identify gaps in the literature, and perform meta-analyses on comparable studies.

METHODS

Relevant studies were identified from searches of PubMed, Embase, Scopus, Web of Science, the Cochrane Library, and the Cumulative Index to Nursing Allied Health Literature and previous systematic reviews. Inclusion criteria were peer-reviewed original data in any language testing an intervention to reduce medication errors in children. Abstract and full-text article review were conducted by 2 independent authors with sequential data extraction.

RESULTS

A total of 274 full-text articles were reviewed and 63 were included. Only 1% of studies were conducted at community hospitals, 11% were conducted in ambulatory populations, 10% reported preventable adverse drug events, 10% examined administering errors, 3% examined dispensing errors, and none reported cost-effectiveness data, suggesting persistent research gaps. Variation existed in the methods, definitions, outcomes, and rate denominators for all studies; and many showed an appreciable risk of bias. Although 26 studies (41%) involved computerized provider order entry, a meta-analysis was not performed because of methodologic heterogeneity. Studies of computerized provider order entry with clinical decision support compared with studies without clinical decision support reported a 36% to 87% reduction in prescribing errors; studies of preprinted order sheets revealed a 27% to 82% reduction in prescribing errors.

CONCLUSIONS

Pediatric medication errors can be reduced, although our understanding of optimal interventions remains hampered. Research should focus on understudied areas, use standardized definitions and outcomes, and evaluate cost-effectiveness.

Safety of medication use in primary care

BACKGROUND

Medication errors are one of the leading causes of harmin health care. Review and analysis of errors have often emphasized their preventable nature and potential for reoccurrence. Of the few error studies conducted in primary care to date, most have focused on evaluating individual parts of the medicines management system. Studying individual parts of the system does not provide a complete perspective and may further weaken the evidence and undermine interventions.

AIM AND OBJECTIVES

The aim of this review is to estimate the scale of medication errors as a problem across the medicines management system in primary care. Objectives were: To review studies addressing the rates of medication errors, and To identify studies on interventions to prevent medication errors in primary care.

METHODS

A systematic search of the literature was performed in PubMed (MEDLINE), International Pharmaceutical Abstracts (IPA), Embase, PsycINFO, PASCAL, Science Direct, Scopus, Web of Knowledge, and CINAHL PLUS from 1999 to November, 2012. Bibliographies of relevant publications were searched for additional studies.

KEY FINDINGS

Thirty-three studies estimating the incidence of medication errors and thirty-six studies evaluating the impact of error-prevention interventions in primary care were reviewed. This review demonstrated that medication errors are common, with error rates between <1% and >90%, depending on the part of the system studied, and the definitions and methods used. The prescribing stage is the most susceptible, and that the elderly (over 65 years), and children (under 18 years) are more likely to experience significant errors. Individual interventions demonstrated marginal improvements in medication safety when implemented on their own.

CONCLUSION

Targeting the more susceptible population groups and the most dangerous aspects of the system may be a more effective approach to error management and prevention. Co-implementation of existing interventions at points within the system may offer time- and cost-effective options to improving medication safety in primary care.

Analysis of electronic medication orders with large overdoses: opportunities for mitigating dosing errors

BACKGROUND

Users of electronic health record (EHR) systems frequently prescribe doses outside recommended dose ranges, and tend to ignore the alerts that result. Since some of these dosing errors are the result of system design flaws, analysis of large overdoses can lead to the discovery of needed system changes.

OBJECTIVES

To develop database techniques for detecting and extracting large overdose orders from our EHR. To identify and characterize users' responses to these large overdoses. To identify possible causes of large-overdose errors and to mitigate them.

METHODS

We constructed a data mart of medication-order and dosing-alert data from a quaternary pediatric hospital from June 2011 to May 2013. The data mart was used along with a test version of the EHR to explain how orders were processed and alerts were generated for large (>500%) and extreme (>10,000%) overdoses. User response was characterized by the dosing alert salience rate, which expresses the proportion of time users take corrective action.

RESULTS

We constructed an advanced analytic framework based on workflow analysis and order simulation, and evaluated all 5,402,504 medication orders placed within the 2 year timeframe as well as 2,232,492 dose alerts associated with some of the orders. 8% of orders generated a visible alert, with ¼ of these related to overdosing. Alerts presented to trainees had higher salience rates than those presented to senior colleagues. Salience rates were low, varying between 4-10%, and were lower with larger overdoses. Extreme overdoses fell into eight causal categories, each with a system design mitigation.

CONCLUSIONS

Novel analytic systems are required to accurately understand prescriber behavior and interactions with medication-dosing CDS. We described a novel analytic system that can detect apparent large overdoses (≥500%) and explain the sociotechnical factors that drove the error. Some of these large overdoses can be mitigated by system changes. EHR design should prospectively mitigate these errors.

Risks to patient safety associated with implementation of electronic applications for medication management in ambulatory care--a systematic review

BACKGROUND

The objective was to find evidence to substantiate assertions that electronic applications for medication management in ambulatory care (electronic prescribing, clinical decision support (CDSS), electronic health record, and computer generated paper prescriptions), while intended to reduce prescribing errors, can themselves result in errors that might harm patients or increase risks to patient safety.

METHODS

Because a scoping search for adverse events in randomized controlled trials (RCTs) yielded few relevant results, we systematically searched nine databases, including MEDLINE, EMBASE, and The Cochrane Database of Systematic Reviews for systematic reviews and studies of a wide variety of designs that reported on implementation of the interventions. Studies that had safety and adverse events as outcomes, monitored for them, reported anecdotally adverse events or other events that might indicate a threat to patient safety were included.

RESULTS

We found no systematic reviews that examined adverse events or patient harm caused by organizational interventions. Of the 4056 titles and abstracts screened, 176 full-text articles were assessed for inclusion. Sixty-one studies with appropriate interventions, settings and participants but without patient safety, adverse event outcomes or monitoring for risks were excluded, along with 77 other non-eligible studies. Eighteen randomized controlled trials (RCTs), 5 non-randomized controlled trials (non-R,CTs) and 15 observational studies were included. The most common electronic intervention studied was CDSS and the most frequent clinical area was cardio-vascular, including anti-coagulants. No RCTS or non-R,CTS reported adverse event. Adverse events reported in observational studies occurred less frequently after implementation of CDSS. One RCT and one observational study reported an increase in problematic prescriptions with electronic prescribing

CONCLUSIONS

The safety implications of electronic medication management in ambulatory care have not been established with results from studies included in this systematic review. Only a minority of studies that investigated these interventions included threats to patients' safety as outcomes or monitored for adverse events. It is therefore not surprising that we found little evidence to substantiate fears of new risks to patient safety with their implementation. More research is needed to focus on the draw-backs and negative outcomes that implementation of these interventions might introduce.

A comparison of nurse attitudes before implementation and 6 and 18 months after implementation of an electronic health record

The implementation of an electronic health record is a dramatic change in a healthcare organization; however, little is known about how nurse attitudes toward the electronic health record change over time. The purpose of this research project was to compare nurses' attitudes before and at 6 and 18 months after implementation of a comprehensive electronic health record. A presurvey-postsurvey design using a modified Nurses' Attitudes Toward Computerization Questionnaire was implemented with a population of nurses employed at an academic medical center. On average, the nurses' attitude about the electronic health record became less positive between preimplementation (n = 312) and 6 months after implementation (n = 410) (74.2 vs 65.9, P < .0001) and preimplementation and 18 months after implementation (n = 262) groups (74.2 vs 67.7, P < .0001). No significant improvement between 6 and 18 months after implementation groups (P = .16) was noted. Prior to electronic health record implementation, the nurses were uncertain yet hopeful about the benefits. However, 18 months after implementing a comprehensive electronic health record, challenges remain regarding cumbersome documentation processes and promoting interdisciplinary communication. Thus, the results demonstrate a gap between preimplementation expectations and the postimplementation reality of the actual experience. Nonetheless, some subjects have experienced positive benefits after implementation of the comprehensive electronic health record and remain hopeful for the future.

Computerized provider order entry and patient safety

Medication errors can lead to significant morbidity and mortality for patients. Children are particularly vulnerable to medication errors. A strategy for reducing medication errors and the harm resulting from these errors is use of computerized provider order entry (CPOE). This article examines the frequency and nature of prescribing errors for pediatric patients. Also discussed are the proposed benefits from CPOE use, including elimination of eligibility errors, ensuring completeness in prescribing fields, reduction in transcription errors, and improved prescribing practices through the use of clinical decision support. The literature on the effect of CPOE in actual use is explored, as are policy implications and directions for future research.

Patient safety in ambulatory care

Understanding of the types and frequency of errors among children in the outpatient setting is paramount. The most commonly described errors involve medical treatment, communication failures, patient identification, laboratory, and diagnostic errors. Research suggests that adverse events and near misses are frequent occurrences in ambulatory pediatrics, but relatively little is known about the types of errors, risk factors, or effective interventions in this setting. This article will review current information on the descriptive epidemiology of pediatric outpatient medical errors, established risk factors for these errors, effective interventions to enhance reporting and improve safety, and future research needs in this area.

Computerized clinical decision support for medication prescribing and utilization in pediatrics

BACKGROUND AND OBJECTIVE

Accurate and informed prescribing is essential to ensure the safe and effective use of medications in pediatric patients. Computerized clinical decision support (CCDS) functionalities have been embedded into computerized physician order entry systems with the aim of ensuring accurate and informed medication prescribing. Owing to a lack of comprehensive analysis of the existing literature, this review was undertaken to analyze the effect of CCDS implementation on medication prescribing and use in pediatrics.

MATERIALS AND METHODS

A literature search was performed using keywords in PubMed to identify research studies with outcomes related to the implementation of medication-related CCDS functionalities.

RESULTS AND DISCUSSION

Various CCDS functionalities have been implemented in pediatric patients leading to different results. Medication dosing calculators have decreased calculation errors. Alert-based CCDS functionalities, such as duplicate therapy and medication allergy checking, may generate excessive alerts. Medication interaction CCDS has been minimally studied in pediatrics. Medication dosing support has decreased adverse drug events, but has also been associated with high override rates. Use of medication order sets have improved guideline adherence. Guideline-based treatment recommendations generated by CCDS functionalities have had variable influence on appropriate medication use, with few studies available demonstrating improved patient outcomes due to CCDS use.

CONCLUSION

Although certain medication-related CCDS functionalities have shown benefit in medication prescribing for pediatric patients, others have resulted in high override rates and inconsistent or unknown impact on patient care. Further studies analyzing the effect of individual CCDS functionalities on safe and effective prescribing and medication use are required.