Integrating a Novel Medication Risk Score and Use of an Advanced Clinical Decision Support System into a Pharmacist- and Nurse-Coordinated Transition of Care Program to Mitigate Drug Interactions

Tranchina K; Turgeon J; * Bingham J;

 Abstract

Purpose: Patients affected by polypharmacy are at higher risk for significant multi-drug interactions. Inadequate management of these multi-drug interactions in patients discharged from the hospital can lead to readmission and/or medication-related morbidity.

Case: The pharmacist identified drug interactions associated with the cytochrome P450 enzymatic system and P-glycoprotein during a medication safety review for an 86-year-old male. Clinical recommendations were made to mitigate these interactions and align the therapeutic regimen with national consensus guidelines based on patient characteristics. Overall, the pharmacist recommended that the provider deprescribe medications found to be unsafe in the elderly to improve the medication risk score associated with medication-related morbidity. 

Conclusion: The interventions recommended by the pharmacist’s interventions decreased the risk of adverse events and may have helped avoid hospital readmission. The case report lends evidence to support a clinical decision support system’s role and its value towards improving patient health outcomes post-hospital discharge.