Adopting real-time surveillance dashboards as a component of an enterprisewide medication safety strategy

Jt Comm J Qual Patient Saf. 2011 Jul;37(7):326-32. doi: 10.1016/s1553-7250(11)37041-9.


Background: High-alert medications are frequently responsible for adverse drug events and present significant hazards to inpatients, despite technical improvements in the way they are ordered, dispensed, and administered.

Methods: A real-time surveillance application was designed and implemented to enable pharmacy review of high-alert medication orders to complement existing computerized provider order entry and integrated clinical decision support systems in a tertiary care hospital. The surveillance tool integrated real-time data from multiple clinical systems and applied logical criteria to highlight potentially high-risk scenarios. Use of the surveillance system for adult inpatients was analyzed for warfarin, heparin and enoxaparin, and aminoglycoside antibiotics.

Results: Among 28,929 hospitalizations during the study period, patients eligible to appear on a dashboard included 2224 exposed to warfarin, 8383 to heparin or enoxaparin, and 893 to aminoglycosides. Clinical pharmacists reviewed the warfarin and aminoglycoside dashboards during 100% of the days in the study period-and the heparinlenoxaparin dashboard during 71% of the days. Displayed alert conditions ranged from common events, such as 55% of patients receiving aminoglycosides were missing a baseline creatinine, to rare events, such as 0.1% of patients exposed to heparin were given a bolus greater than 10,000 units. On the basis of interpharmacist communication and electronic medical record notes recorded within the dashboards, interventions to prevent further patient harm were frequent.

Conclusions: Even in an environment with sophisticated computerized provider order entry and clinical decision support systems, real-time pharmacy surveillance of high-alert medications provides an important platform for intercepting medication errors and optimizing therapy.

MeSH terms

  • Aminoglycosides / adverse effects
  • Anticoagulants / adverse effects
  • Communication
  • Decision Support Systems, Clinical / organization & administration*
  • Humans
  • Medical Records Systems, Computerized / organization & administration
  • Medication Errors / prevention & control*
  • Pharmacy Service, Hospital / organization & administration*
  • Safety Management / organization & administration*


  • Aminoglycosides
  • Anticoagulants