Impact of a warning CPOE system on the inappropriate pill splitting of prescribed medications in outpatients

The article was published in 2014 in PLOS ONE, the world’s first multidisciplinary Open Access journal.

Background

Splitting of extended-release (ER) or enteric-coated (EC) oral drugs can lead to adverse drug events (ADE). To reduce inappropriate pill splitting, the authors developed an automatic warning system within CPOE in an outpatient setting of a hospital. The study assessed the impact of the system and physicians responses.

Methods

The authors designed a real time pop up on the CPOE screen. The message was “Drug should not be split. Please revise the prescription.” Physicians had to change the prescription or select another medication. The study compared inappropriate splitting before and after the implementation of the warning system.