Table 1

Summary of the results

Author, year	Study population	Sample size	Intervention	Outcome	Significant outcomes
Donovan et al 201018	LTC residents Mean age=85.8	n=813	Randomised trial conducted at a long-term care facility equipped with an integrated EMR and CPOE over a 1-year period. Randomisation was within blocks according to resident unit type. CDSS for 22 psychotropic medications was developed. CDSS had 2 broad alert categories; ‘dosing’ and ‘avoid’ to identify inappropriate psychotropic medication orders	The overall rates of inappropriate orders Percentages of medication orders that were modified in response to alerts	CDSS provided to prescribers influenced prescribing decision, although no overall improvement in prescribing quality was noted.
Field et al 200919	LTC residents Mean age=86.3	n=833	Randomised trial within the long-stay units of a long-term care facility. Alerts related to medication prescribing for residents with renal insufficiency were displayed to prescribers in the intervention units and hidden but tracked in control units. 4 types of alerts were developed: (1) recommended medication doses, (2) recommended administration frequencies, (3) to avoid the drug and (4) warnings of missing information. Alerts were measured over 1-year period	Proportion of final drug orders that were appropriate	CCDSS for physicians prescribing medications for LTC residents with renal insufficiency improved the quality of prescribing decisions. Higher proportions of final drug orders were appropriate in the intervention units (RR=2.4, 1.4 to 4.4 for maximum frequency; RR=2.6, 1.4 to 5.0 for drugs that should be avoided; and RR=1.8, 1.1 to 3.4 for alerts to acquire missing information). Final drug orders were appropriate significantly more often in the intervention units (alerts displayed) with a RR of 1.2 (1.0 to 1.4).
Gurwitz et al 200828	LTC residents Mean age=87.2	n=1118	29 resident care units were randomised to having a CCDSS or not. In the intervention unit, prescribers were presented with alerts while alerts were not displayed to prescribers in the control units over a 1-year period	Number of ADE, severity and preventability of the events	CPOE with DSS did not reduce ADE rate or preventable drug event rate in the LTC.
Handler et al 200827	All nursing home residents except those enrolled in hospice	n=274	A clinical event monitor (a type of CCDSS) implemented and evaluated in the detection of ADR in a nursing home over 15-week period	PPV of signals that detected ADR, the amount of preventable ADR and serious ADR	ADR can be detected in the nursing homes with a high degree of accuracy using a clinical event monitor. The overall PPV for all signals was 81%. Of the true positive findings, one-third of the ADR were considered preventable. Of the preventable ADR, 88% occurred at the monitoring and 69% at the prescribing stage.
Judge et al 200622	Residents in the long-stay units of the LTC	n=445	RCT of CCDSS in the long-stay units of a long-term care facility. CCDSS was added to an existing CPOE system. Over 1-year, prescribers in the intervention units were presented with alerts and prescribers in the control units were not displayed alerts. CCDSS was designed to provide alerts on: (1) drug interactions, (2) danger related to the ordered medication, (3) risk of adverse effects, (4) dose ranges and (5) likelihood of adverse drug effects	The proportion of alerts that were followed by an appropriate action	Of 47 997 medication orders, 9414 alerts were triggered (2.5 alerts per resident per month); 20% central nervous system-related side effect alerts such as oversedation, 13% drug-associated constipation alerts, 12% renal insufficiency/electrolyte imbalance alerts and 12% warfarin-related alerts. CCDSS with CPOE is effective in presenting alerts, therefore represents as a tool to improve medication safety. Prescribers who received alerts were only slightly more likely to take an appropriate action (RR=1.11, 95% CI 1.00 to 1.22).
Kennedy et al 201120	Residents in LTC with renal impairment. Mean age=87.0±7.4	n=1196	A CCDSS developed in partnership with a large pharmacy provider that generated renal prescribing alerts. 7 LTC across Ontario, Canada participated in a 3-month programme evaluation	The number of alerts and the physician response to alerts	Physicians responded to 70% of the alerts with a dose change or medication discontinuation. During the 3 months’ duration, 446 alerts were generated in 321 residents; 27% of all residents received at least 1 alert.
Tamblyn et al 201221	Patients aged 65 and older who were prescribed psychotropic medication Mean age=75.2	n=5628	Cluster RCT intervention tested whether CDSS with patient-specific risk estimates would increase physician response to alerts and reduce the risk of injury in older adults over a 2-year period. Physicians in the intervention unit received a patient-specific risk of injury alert when a patient was prescribed a psychotropic medication that increased the risk of injury while physicians in the control unit received commercial drug alerts. In a secondary analysis, physicians’ response to the injury risk alert and changes in the use and dose of psychotropic medications were assessed	Injury risk at the end of follow-up based on psychotropic drug doses and non-modifiable risk factors	CCDSS with patient-specific risk estimates provide an effective method to reduce the risk of injury for vulnerable older adults. The intervention reduced the risk of injury by 1.7 injuries/1000 patients (95% CI 0.2/1000 to 3.2/1000; p=0.02). The effect of the intervention was greater for patients with higher baseline risks of injury (p<0.03). Intervention physicians reviewed therapy in 83.3% of visits and modified therapy in 24.6% visits.

ADE, adverse drug events; ADR, adverse drug reactions; CCDSS, computerised clinical decision support system; CDSS, clinical decision support system; CPOE, computerised physician order entry; DSS, decision support system; EMR, electronic medical records; PPV, positive predictive value; RCT, randomised controlled trials; RR, relative risk; LTC, long-term care home.