Denver, Colorado
The Drug Renal Alert Pharmacy (DRAP) Program: Improving Prescribing Safety in Patients with Renal Insufficiency in the Ambulatory Setting
Appropriate medication selection and dose adjustments are important for safe medication use in patients with kidney disease. However, few studies have evaluated ways to improve prescribing safety among outpatients with reduced kidney function. A 2002 Kaiser Permanente Colorado (KPCO) needs assessment revealed that compliance with medication dosing guidelines for patients with decreased kidney function was problematic. This assessment revealed that over fifty percent of target medication prescriptions included doses that were too high, given the patients’ kidney function.
As a result, KPCO conducted a study to determine whether a computerized Drug Renal Alert Pharmacy (DRAP) program could decrease the rate of medication errors in drug selection or dosing for 15 target medications in patients with decreased kidney function. The DRAP program was used to alert pharmacists at the time that medications were dispensed of possible errors in medication selection and dosing for patients with decreased kidney function. The 15 target medications were previously identified based on frequency of use in the KPCO health care system and risk of serious adverse events.
A total of 32,917 health plan members were randomly assigned to either an intervention group (16,577 patients) or a usual care group (16,340 patients). The health plan members assigned to the study had to be at least 18 years old and have decreased kidney function. However, they could not be receiving dialysis. Of the 32,917 patients, it was determined that 6,125 patients (3,025 in the intervention group and 3,100 in the usual care group) were prescribed at least one target medication and were included in the analysis.
For the study, “medication error” was defined as prescribing target medications that should be avoided or inappropriate doses. Compared to the usual care group, the intervention group experienced a 33% reduction in rate of errors over the 15-month intervention period. After the study period, when the intervention was expanded to both groups, the sustainability of the program was demonstrated with a 49% reduction in rate of errors in the combined groups during the subsequent 7 months.
The DRAP program was successful in reducing medication errors for outpatients with decreased kidney function and was sustained after the study’s completion. Based on the results of this study, the DRAP program was launched in all KPCO outpatient pharmacies in April 2006 and continues to function as an important safety clinical decision support intervention for its patients.