While Clinical Decision Support Systems (CDSS) can be developed as a large group of rules- based advice occasionally, cases of preventable adverse drug events come to the attention from various pathways, both through clinical and policy activities. At Partners HealthCare Systems, there is a centralized knowledge management structure that allows for clinicians to present information to a Medical Knowledge Committee (MKC) in a structured way so that any information can be properly vetted. A case of a fatality due to the administration of 2 medications concurrently and the understanding that key decision support components were not available to the prescribing clinicians, drove us to implement this advice in both our acute care and ambulatory clinical systems.
