The DOCUMENT system provided pharmacists with a useful and easy-to-use tool for recording DRPs and clinical interventions. Results from the trial have provided a better understanding of the frequency and nature of clinical interventions performed in Australian community pharmacies, and lead to a national implementation of the system.

These data illustrate the prevalence of drug-related problems and the ability of pharmacists to identify these problems in the Australian models of medication review. The nature and frequency of problems varied between reviews for home-dwelling and care-facility patients. Such information may be used to better focus the training of practitioners based on the most frequently encountered health problems and the nature of common drug-related problems in the two settings.

What is already known about this subject • Computerized prompts and reminders have been shown to be effective in changing the behaviour of health professionals in a variety of settings. • There is little literature describing or evaluating electronic decision‐support for pharmacists. What this study adds • An electronic prompt in dispensing software for a targeted clinical intervention has a significant effect on pharmacists' behaviour. A markedly increased rate of recording and performing the targeted clinical intervention was found. • The effect of the prompt reduces markedly once the prompt is deactivated. Aim To evaluate the effect of an electronic prompt in dispensing software on the frequency of clinical interventions recorded by community pharmacists. Method An electronic decision‐support prompt identifying patients for a targeted proactive clinical intervention was developed and implemented. Each time an oral antidiabetic agent was dispensed, a prompt was displayed reminding pharmacists to discuss the suitability of aspirin therapy in eligible patients with diabetes. The prompt was randomly assigned to 31 of 52 metropolitan pharmacies in Melbourne (Australia) for 6 weeks, with the remaining pharmacies as controls. Results One hundred and fifty pharmacists in 52 pharmacies recorded a total of 2396 clinical interventions at an intervention rate of 0.92 interventions per 100 patients [95% confidence interval (CI) 0.58, 1.23]. Pharmacists recorded a total of 201 target interventions related to aspirin therapy in diabetes at an intervention rate of 2.55 interventions per 100 diabetic patients (95% CI 0.85, 4.24). All of the targeted clinical interventions were recorded in the prompt arm; no targeted interventions were recorded in the control group. The effect of the prompt decreased over the study period and was not maintained after prompt deactivation. Conclusion An electronic prompt significantly increased pharmacists' recording of the targeted clinical intervention in diabetic patients. An electronic decision‐support prompt has significant potential to promote community pharmacists' contribution to the quality use of medicines.

Inappropriate prescribing, as defined by either Beers criteria or McLeod criteria, is relatively common in Australian nursing homes. The prevalence of inappropriate prescribing, and factors influencing it, are consistent with other countries. Both Beers and McLeod criteria are a general guide to prescribing, and do not substitute for professional judgment.

WHAT IS ALREADY KNOWN ABOUT THIS SUBJECT• Computerized clinical decision support has been increasingly utilized in hospital and general‐practice settings where it may improve prescribing practice. Little investigation has been undertaken using computerized decision support in the community pharmacy setting. Proton pump inhibitors are expensive and often prescribed in dosages above recommended guidelines.WHAT THIS STUDY ADDS• This study adds justification for the use of computerized decision support in community pharmacy. It highlights the promotion of improved prescribing of proton pump inhibitors through patient empowerment.AIM To evaluate the effect of a computerized decision support prompt regarding high‐dose proton pump inhibitor (PPI) therapy on prescribing and medication costs.METHODS A prompt activated on dispensing high‐dose esomeprazole or pantoprazole was implemented in 73 of 185 pharmacies. Anonymized prescription data and a patient survey were used to determine changes in prescribing and associated medication costs.RESULTS The pharmacist‐recorded PPI intervention rate per 100 high‐dose PPI prescriptions was 1.67 for the PPI prompt group and 0.17 for the control group (P < 0.001). During the first 28 days of the trial, 196 interventions resulted in 34 instances of PPI step‐down, with 28 of these occurring in PPI prompt pharmacies. Cost savings attributable to the prompt were AUD 7.98 (£4.95) per month per PPI prompt pharmacy compared with AUD 1.05 (£0.65) per control pharmacy.CONCLUSION The use of electronic decision support prompts in community pharmacy practice can promote the quality use of medicines.

The documentation system allowed for the determination of the frequency and types of DRPs, as well as the recommendations made to resolve them in community pharmacy practice. Use of the software, including its electronic prompts, significantly increased the documentation of interventions by pharmacists.

The knowledge-based system has already demonstrated that the technique employed is well suited to a domain of this nature and has furthermore demonstrated that it is capable of improving the quality of service that the medication reviewer can provide. The system will be further enhanced and tested prior to use in the field. It should help pharmacists in the provision of medication reviews, improving their clinical and time management capabilities, and enhancing their ability to contribute to the quality use of medications.

This considerably reduced requirement for warfarin prompted a retrospective review of medical records at our hospital for the period 1981-6 to examine whether there might be an interaction between tamoxifen and warfarin. The records of women with breast cancer and a subsequent admission for a serious thromboembolism were examined. There were 18 such women: seven who had had deep venous thrombosis and 11 who had had a pulmonary embolus with probable deep venous thrombosis. Five of them were taking tamoxifen when they started taking warfarin. Two of them had complications after loading doses of warfarin: in one the prothrombin time after three daily doses of warfarin (10 mg, 10 mg, and 5 mg) rose to 50 seconds, and she developed a left subdural haematoma requiring warfarin to be withdrawn; in the other a similar loading dose regimen resulted in a prothrombin time of 49 seconds on day 7, the patient developed severe haematuria, and her anticoagulant treatment was changed to phenindione. The three other patients taking tamoxifen required daily doses of 2 mg, 2 mg, and 3 mg to maintain appropriate prothrombin times.The dose of warfarin that maintained appropriate prothrombin times in the 13 patients not taking tamoxifen varied from 4 to 10 mg (mean 6 25 mg) daily. None of these patients had complications in the first month of treatment with warfarin. CommentOur observations suggest that women with breast cancer requiring warfarin need a lower dose if they are taking tamoxifen. The mechanism of the interaction between the two drugs is unclear, but protein binding and competition for metabolic pathways may both play a part. Both warfarin and tamoxifen are metabolised by the microsomal enzyme systems in the liver. Warfarin is a racemic mixture and the (S) isomer is four to five times more physiologically active than the (R) isomer. This more active (S) isomer is converted to the 7-hydroxy metabolite, which is inactive, by the cytochrome P450 enzyme system.2 Three metabolites have been detected in the serum ofpatients taking tamoxifen. Normally tamoxifen accounts for 36% of the drug and metabolites present, desmethyltamoxifen for 58%, metabolite Y for 4%, and 4-hydroxytamoxifen for 1-5%.3 All of these metabolites have some affinity for the oestrogen receptor, but the affinity of the 4-hydroxy metabolite is 50-100 times greater than that of the parent drug.4 Accordingly, 4-hydroxytamoxifen is about 100 times more potent than tamoxifen in inhibiting the growth of MCF7 breast cancer cells in culture.5The hydroxylations are probably carried out by similar enzyme systems. In the case of warfarin competition for the enzymes may increase the concentration of the active parent drug and decrease the concentration of inactive metabolites. In the case of tamoxifen, however, the resultant changes in the amounts of metabolites present may have important implications for the activity of the drug. Altering the percentage of the 4-hydroxy metabolite present may have an effect on the response of the tumour.The hazards of an increased pha...