INTRODUCTION:

Medication-related problems may increase the likelihood of poor clinical outcomes in critically sick patients. Because of the intricacy of their clinical course and the frequency of medication-related occurrences, critically ill patients are frequently thought to be especially susceptible to the detrimental effects of these issues. Sepsis is the tenth highest cause of death overall and a significant cause of morbidity and mortality in the critical care unit.^1,2 Every year, millions of individuals worldwide suffer from sepsis and septic shock, and between one in three and one in six of them die as a result of these serious illnesses.^3–5 Early detection and effective care in the early hours following the onset of sepsis are two essentials for managing sepsis in order to enhance the clinical prognosis for the patient.⁶ In order to properly treat drug-related problems in the intensive care unit, a number of crucial procedures depend on the clinical pharmacist. ICU clinical pharmacists can improve clinical outcomes, reduce the risk of medication-related problems, and increase patient safety. Improving outcomes depends on the detection and treatment of sepsis consequences, including organ failure. The cumulative load of sepsis consequences is a significant contributor to death, and DRPs have an effect on the patient's clinical state. Mortality increases by 20% for each failure. One practical method for reducing DRPs and enhancing the suitability of medication therapy is the use of clinical decision support systems (CDSS) by pharmacists.⁷

MATERIALS AND METHODS:

Data on how pharmacists use clinical decision support systems to manage drug-related problems (DRPs) in sepsis patients in the intensive care unit (ICU) form the basis of this research study, which is sometimes referred to as a literature review study or descriptive analysis. Google Scholar, Science Direct, and Pubmed were used to locate the literature. Documents in the form of original papers published between 1994 and 2024 were the initial reference for this journal. Research on clinical decision support systems used by pharmacists for drug-related problems (DRPs) in patients with hospitalized or intensive care unit (ICU) sepsis is included in all of the selected papers. Based on the content of the articles found through abstract searches and discussions, the distribution of research is grouped based on predetermined criteria. Using a descriptive analysis paradigm, the main idea of each piece is briefly explained in paragraphs. The following is the flow of the literature review used in research:

Figure 1. Literature Review Flow

Finding articles that fit the criteria, assessing and analyzing them, and finally reporting or publishing the research findings are the next steps after planning. With regard to drug-related problems (DRPs), this study aims to map the distribution of research on pharmacists' use of clinical decision support systems, particularly in sepsis patients and the intensive care unit (ICU) in general.

RESULT AND DISCUSSION:

Drug Related Problems:

Finding and managing Drug-Related Problems (DRPs) is essential to improve the efficacy and safety of drug therapy, as well as helping patients achieve the best health outcomes, especially in critical patients such as those admitted to the ICU with sepsis. ^6,8–10

Critical patients receive twice as much medication as non-critical patients, increasing the likelihood of adverse drug effects. The realities of treatment are reflected in this. It is essential to thoroughly evaluate and regularly monitor pharmaceutical therapy in critically ill patients in order to reduce the risk of DRPs and adverse outcomes.^11,12 Therefore, it is essential to thoroughly assess and constantly monitor pharmacological therapy in sick patients in order to reduce the risk of DRPs and adverse effects.^13–16

Because critically sick patients receive twice as much medication than non-critically ill patients, adverse drug events are more likely to occur in these patients.¹⁷ Drug-drug interactions,¹⁸ drug buildup from multiple organ dysfunction, and sensitivity to medication reactions due to labile condition are all more common in intensive care unit (ICU) patients. Changes in the pharmacokinetic and pharmacodynamic properties of medications, the severity of the patient's illness, the presence of multiple chronic diseases, drug interactions, and polypharmacy—the use of multiple medications—are some of the factors that affect how complicated a patient's treatment plan is.^19,20

Depending on the reference guide used, different DRP types are classified using different theories, such as Cipolle/Morley/Strand theory, Hepler-Strand theory, American Society of Hospital Pharmacists theory, Myeboom ABC theory theory, Granada Consensus theory, and Pharmaceutical Care Network Europe (PCNE) version 9.1.^8,21–25 In clinical pharmacy services, a pharmacist's duties include identifying, preventing, and managing medication-related problems.²⁶ Contributions from pharmacists can lessen the effect of DRPs.^17,27–30 Several studies of drug-related problems in sepsis patients in hospitals can be seen in (table 1).

Role of Pharmacists:

Some of the roles of pharmacist interventions in the ICU have an impact on:

1. Overdosing or underdosing, followed by improper drug selection, are examples of DRP types. A 75% change in therapy was the most often suggested remedy by pharmacists to address this problem. In the most common categories of therapeutic changes, the three most common recommendations were to "need to prescribe medication" (26%), stop taking medication (15%), and change the frequency or dosage (12%). The therapeutic medicine groups that required the most intervention were anti-infectives (18%), cardiovascular (13%), analgesics (10%), gastrointestinal (8%), psychotropics (8%), blood and electrolytes (7%), endocrine (7%), respiratory (7%), other (4%) and 4% for neurological drugs.⁴⁰

2. Drug expenses can be decreased by pharmacist participation in the intensive care unit's (ICU) multidisciplinary team. An annual savings of $67,664 was observed in one study in the medical-surgical intensive care unit. Results from other research have been conflicting; for instance, the burn intensive care unit saw yearly savings of $22,162. Drug expenses per patient in the neurosurgical intensive care unit dropped from $4,833 to $3,239 following the addition of a pharmacist to the team. Additionally, with a p-value of 0.003, which indicates statistical significance, the length of stay in the intensive care unit was shortened from 8.56 days to 7.24 days, suggesting increased care efficiency.⁴¹

3. Reduction of adverse drug reactions and drug interactions.

The number of avoidable adverse medication events in the medical intensive care unit (ICU) decreased by 66% after pharmacists were included in the interdisciplinary team. This result is highly statistically significant, as indicated by the p value <0.001, indicating that pharmacists significantly improve patient safety in the intensive care unit by lowering medication-related errors or issues;⁴² supported by a meta-analysis of three studies with an Odds Ratio (OR) of 0.23.⁴³ Decreases the likelihood of both avoidable and non-preventable pharmacological adverse effects; for preventable side effects, the OR is 0.26 and p<0.0001, while for non-preventable side effects, it is 0.47 and p=0.003.⁴⁴ QTc interval prolongation was less common when pharmacists in the intensive care unit monitored patients using a conventional procedure;19% versus 39%, with p=0.006.⁴⁵ Findings: There were 65% fewer drug interactions in the medical intensive care unit when pharmacists were involved. This drop is highly statistically significant, as indicated by the p-value <0.01, suggesting that pharmacist engagement effectively lowers the risk of patient harm from drug interactions.⁴⁶

4. The decrease in illness, death, and expenses:

ICUs without a clinical pharmacist had significantly higher death rates than those with one: sepsis was 4.8% higher (p≤0.008), nosocomial infections were 23.6% higher (p<0.001), and community-acquired diseases were 16.2% higher (p=0.008). The length of stay was also longer in intensive care units without a clinical pharmacist: it was 7.9% longer for nosocomial infections (p<0.001), 5.9% longer for community-acquired illnesses (p=0.03), and 8.1% longer for sepsis (p<0.001). Additionally, ICUs without a clinical pharmacist had higher Medicare billing expenses than ICUs with one: p<0.001 for sepsis, nosocomial infections, and community-acquired diseases were all higher by 12.9%, 11.9%, and 11.9%, respectively.⁴⁷

5. Mortality and LOS Decrease

14 studies on critical care pharmacists as multidisciplinary team members were meta-analyzed. Decreased LOS: mean -1.33 days, p<0.00001, and decreased mortality: OR 0.78, p<0.00001. Pharmacist participation in a multidisciplinary program to reduce sepsis-related mortality in the ICU resulted in a reduction in the time from sepsis screening to antibiotic administration from 427 minutes to 31 minutes. ICU pharmacy interventions were also effective in reducing mortality and length of stay (LOS). Pharmacist management of sedation decreased the time on ventilators and reduced hospital and ICU LOS (p < 0.001). In addition, strategies involving pharmacists in managing agitation, delirium, pain, and sedation also decreased mortality and LOS, and reduced ICU LOS (1.4 days), mechanical ventilation (1.2 days), and hospital stay (3.7 days), although there was no significant change in mortality. ^44,48–51

6. Other impacts:

a. When compared to empirical therapy, the implementation of a protocol resulted in a significant improvement in meeting sedation and analgesia monitoring targets p≤0.01.⁵²

b. Albumin use in critically ill patients at one academic medical center: a retrospective cohort study 50.9% less incorrect e-albumin was used (p<0.001), and almost $355,000 was saved annually.⁵³

Intensive Care Unit (ICU):

The highest level of patient care, known as intensive care, is reserved for critically sick patients with potentially fatal illnesses who are yet treatable.⁵⁴ Multidisciplinary and interprofessional expertise tailored to the treatment of patients with life-threatening organ failure or at risk of developing it is necessary for intensive care in critically sick patients.^55–57 The ICU is responsible for the ongoing care and observation of patients with life-threatening illnesses.⁵⁵ Maintaining essential functions in critically ill patients is the goal of intensive care in order to stop further physiological deterioration, lower mortality, and avoid morbidity.^55,58

A solid, diversified team of medical experts with a range of abilities to support patient care is necessary while caring for critically ill patients. Clinical pharmacists are advised to be part of intensive care unit teams by the Society of Critical Care Medicine (SCCM).⁵⁹ For critically ill patients, ICU pharmacists must monitor pharmaceutical therapy and offer management assistance. Details of the duties of critical care pharmacists have been thoroughly described by the American College of Clinical Pharmacy, SCCM, and the American Society of Health-System Pharmacists.⁶⁰

Critical care pharmacists play a role in all aspects of drug therapy, such as adjusting doses, checking for drug interactions, providing education, and helping to select therapy based on test results. They also often provide important information about the patient's history, especially since ICU teams often change. In addition, pharmacists manage care transitions, such as changing from injectable to oral medications, to prevent medication errors.⁶¹

Clinical Decision Support System (CDSS):

Software or computer systems known as clinical decision support systems (CDSS) are made to help medical professionals make judgments regarding specific patients at a given moment. Clinical decision-making is influenced by CDSS, which enhances the quality of healthcare by connecting clinical observations with medical knowledge.⁶² A review of CDSS's efficacy by integrating it with hospital medical records revealed that it improved the quality and safety of prescription drug prescriptions, decreased the rate of prescribing errors, improved communication between patients and healthcare providers, and increased the use of preventive care among hospitalized patients.⁶³

The outcomes evaluated in the CDSS assessment can be classified into seven main categories: clinical (duration of hospitalization, morbidity, mortality, health-related quality of life, adverse events), relationship-focused (patient satisfaction), health care provider workload, efficiency and organization (number of patients served per unit time, physician workload, efficiency), and health care process; adoption/implementation of preventive care/clinical studies/treatments recommended by the CDSS, patient adherence to CDSS recommendations, impact on user knowledge.⁶⁴ Previous studies can be seen in (table 2).

Table 2. Some CDSS Studies in Patient Care

CDSS Type	Research Design	Research Result
CDSS Adverse Drug Reactions (ADR)	1. Identification and prevention of adverse drug reactions/ADRs with a computerized information system in the United States.⁶⁵	133 ADRs identified. Dosage factors, laboratory results, drug-patient characteristics are the main factors. Identified ADRs are preventable.
	2. Identification of ADE/ADRs with CDSS: A retrospective and prospective study (excluding ICU patients) over 1 month, with a prospective comparison over 6 months in an internal medicine ward, The Netherlands.⁶⁶	Conventional drug monitoring detects drug interactions and overdoses, while computer-based CDSS provides alerts about impaired renal function, laboratory abnormalities, and concomitant drug effects. Prospective CDSS detects more ADRs than conventional methods.
	3. CDSS identification of ADRs. Identifying clinically inpatients at high risk of ADRs with a prospective cohort design. Netherlands.⁶⁷	Identification in Total 3459 patients. 8% of 1730 patients were in high-risk group, and 35% of 137 had at least one ADRs.
CDSS Drug-Drug Interactions	1. Software-based drug-drug interaction CDSS in identifying drug-drug interactions and managing DRPs in patients with cardiovascular surgery under the name Pharmavista inpatients in Switzerland.⁶⁸	On average, 303 patients were taking 17 medications, with 201 patients experiencing 346 drug-related problems, or about 1.1 per patient. 44% of the problems were due to drug interactions. The software-based system generated 1,370 alarms (4.5 per patient), but 89% were not clinically relevant, and only 147 were consistent with manual observations.
CDSS Drug-Drug Interactions	2. The CDSS Drug Interactions used a prospective method on electronic prescription and medical data, with a retrospective comparative intervention design (before-after), conducted in a three-month trial in hospitalized patients in Vietnam.^69,70	There was a significant reduction in patients with drug interactions (from 4.27% to 3.56%) and contraindications (from 39.33% to 27.59%), indicating that the intervention successfully improved safety and adherence to clinical protocols, resulting in safer and more effective patient care.
CDSS Dosage	The CDSS warnings on drug dosing were replaced with a prospective observational study involving clinicians, conducted in patients in adult intensive care units at two hospitals in the United States between September 2016 and April 2017.⁷¹	In the study, 93% of ICU patients experienced an overdose. Treatment compliance reached 88.8% in 755 patients. Insulin infusion often triggered high-dose warnings. Adverse drug events were higher when false warnings were ignored (5.0) compared to correct warnings (1.3).
Antibiotic CDSS	1. Computer-based antibiotic dose CDSS with pre-intervention and post-intervention study design, with consecutive sampling technique in 12-bed ICU for shock and trauma patients, and respiratory disorders. User: Pharmacist Country: United States.⁷²	Of the 8,901 patients before the intervention, 4,494 (50%) received one of the five antibiotics studied. During the intervention, 1,974 (44%) of the 4,483 patients received an excessive dose. P values < 0.001 and 0.02 indicate a significant difference in antibiotic doses. In addition, spending on antibiotics was $98 lower during the intervention compared to before the intervention.
	2. The CDSS for antibiotics in respiratory disease was implemented from 11 November 2015 to 9 August 2016, with the last follow-up on 9 August 2017. Data were collected from a control group for 12 months, while the CDSS users were clinicians following NICE guidelines in the UK.⁷³	For antibiotic prescriptions, the unadjusted and adjusted rate ratios were 0.89 and 0.88, respectively, with P=0.04. Adults between the ages of 15 and 84 saw the biggest decline in antibiotic prescriptions.
	3. Bronchitis Antibiotic CDSS with RCT design in 33 primary care practices in Pennsylvania from October 1, 2009 to March 31, 2010. CDSS is synchronized with electronic and manual or printed medical records. Physician users in the United States.⁷⁴	Implementation of CDSS, both paper-based and computer-based, has been successful in increasing appropriate antibiotic use and reducing misuse in adolescents and adults. Analysis shows that CDSS helps improve decision-making, improving the quality of patient care.
	4. The software-based antibiotic CDSS analyzed pre- and post-use data in the ICU, NICU, surgical units, and pharmacy over 11 months. 20 alerts were used for drugs such as vancomycin and piperacillin tazobactam. Users: Pharmacists in the US.⁷⁵	The implementation of CDSS in the pharmacy department has successfully increased the number of clinical interventions by 105%, as well as generating significant annual cost savings of almost $3 million and a high return on investment. This shows that CDSS not only improves the quality of care, but also the cost efficiency in healthcare.
	5. Accuracy of CAP CDSS antibiotic prescribing by study design: Pre-intervention and post-intervention cohort study.⁷⁶	Of the 133 patients, antibiotic therapy compliance increased significantly thanks to the use of CDSS, with an Odds Ratio (OR) of 1.99 and p = 0.02 indicating significant results.
	6. Computer-based CDSS for antibiotics and anti-infectives using a pre- and post-intervention design in a 12-bed ICU for 1 year (intervention group) and 2 years (control group). Users: Pharmacists.⁷⁷	Allergy reports, antibiotic sensitivity discrepancies, and drug overdose cases each decreased significantly (P<0.001). Patients who participated in the CDSS experienced a decrease in overdose days and adverse drug events. Hospital costs and length of stay were lower in the intervention group compared to controls (P<0.001).
	7. CDSS of antibiotic and resuscitation fluid administration in septic shock patients in the emergency department (ED) with a prospective study design categorized by time from triage and time from shock recognition to antibiotic initiation. The primary outcome was in-hospital mortality.⁷⁸	Delays in administering antibiotics were linked to higher fatality rates in a prospective analysis of 291 ED patients suffering from septic shock.
CDSS In Renal Insufficiency	1. Study comparing CPOE with CPOE plus CDSS dose in patients with renal insufficiency for 2 months. Users: Physicians. Population: Surgical, neurology, and obstetric patients. Sampling technique: Consecutive sampling.⁷⁹	Of 97,151 drugs affecting the kidney, 15% had their doses adjusted by the computer system. The intervention group had 67% correct dose adherence, higher than controls (54%), and received correct prescriptions more often (59% vs 35%, p<0.001). Length of hospital stay was shorter in the intervention group (4.3 days vs 4.5 days, p=0.009).
	2. This study used CDSS and CPOE to adjust drug doses in patients with renal impairment in US EDs, focusing on the proportion of drugs overdosed in adult patients.⁸⁰	Decision support was provided 73 times to physicians in the intervention group, who administered 31 doses (43% of prescriptions). In the control group, 34 of 46 physicians (74%) administered the higher dose. An effect size of 31% indicated a significant difference, with P = 0.001.
	3. CDSS with integrated drug dose adjustment in CPOE helps pharmacists adjust drug doses based on kidney function. The system provides warnings and dose recommendations. A quasi-experimental study was conducted with a before-and-after intervention design.⁸¹	The study showed an increase in appropriate prescribing based on renal function from 65% to 86% (p<0.001) after the intervention. The intervention was performed more frequently in the emergency room (45%). Pharmacists saw 28 patients daily, and the computer-based medication dosing method reduced prescribing errors in patients with renal insufficiency.
CDSS Prescription Errors in the Pediatric Intensive Care Unit (PICU)	1. CPOE with PICU CDSS with a retrospective before and after study design. Population: pediatric patients. The total sample size was 840 (N before = 420 and N after = 420). Country: United States.⁸²	724 prescriptions were written for 840 individuals (420 patients prior to intervention and 420 patients following it), with 21% of those prescriptions containing mistakes. Compared to 18.3 errors per 100 prescriptions without the CDSS, the error rate in this group was 1.9 errors per 100 orders on the CDSS.
	2. CDSS prescription errors PICU with research design: retrospective observational. Number of prescriptions 9342 prescriptions in the 4 month period before and after the implementation of CDSS in the Netherlands.⁸³	After CDSS implementation, prescription deviations decreased from 0.89% to 0.49% (p=0.02), and dosage deviations exceeding recommended limits decreased from 0.74% to 0.39% (p=0.03).
	3. Observational study at PKU Muhammadiyah Hospital Yogyakarta and Sleman Hospital to identify DRP in pediatric outpatients using CDSS, with retrospective data collection from October to December 2014.⁸⁴	Potential DRPs identified by pharmacists using pharmacy support software occurred in 125 (63.13%) outpatient pediatric patients with an incidence of 232 DRPs. Pharmacy support software has a sensitivity of 96.5%; specificity of 62.5%; positive predictive value of 66.4% and negative predictive value of 95.8%.
CDSS in Intensive Cardiology Care Unit (ICCU) Patients	CPOE with CDSS in Cardiac intensive care unit with cohort study design with treatment duration of 3 months. Specific parameters: dosage, duplicate therapy, potential interactions and allergies. User: pharmacist in the United States.⁸⁵	After implementation of CPOE accompanied by CDSS, the adjusted mean monthly mortality rate decreased by 20% (P=0.03). Comparative analysis between observed and predicted mortality rates showed that implementation of CPOE with CDSS reduced 36 deaths over the 18-month period following implementation.
CDSS Appropriateness of Prescribing in Geriatric Patients	1. CDSS appropriateness of prescribing in geriatric patients which then measures the impact of pharmacist interventions in assessing appropriateness of prescribing in geriatric patients and measures the level of acceptance of recommendations generated prospectively over 12 months starting from patient admission and day 7-10 or when the patient goes home.⁸⁶	A total of 361 patients received an average of 9 and 12 drugs at hospital admission and discharge, respectively. CDSS resulted in a significant increase in prescription appropriateness p<0.001.
	2. CDSS for elderly patients: A 13-month treatment and 2-month control RCT study, to detect problems such as drug interactions, inappropriate dosing, contraindications, and duplication of therapy. Users: Physicians in Canada.⁸⁷	The use of CDSS helped reduce inappropriate prescriptions in patients, with the CDSS group having a lower number than the control group. In addition, the Risk Ratio (RR) value showed the difference in risk for problematic new prescriptions, duplication of therapy, and drug interactions between the two groups, indicating the effectiveness of CDSS in improving medication safety.
	3. CDSS or pharmacy support system elderly dose with prospective controlled trial design. Geriatric patient population. Geriatric population, patients ≥65 years. Total sample N = 1407 (n cases = 739; N controls = 668). Country: United States.⁸⁸	Most drug change suggestions were rejected (92.5%). During treatment, more prescriptions were appropriately dosed (31.4%) compared to controls (23%) p<0.0001. Side effects were lower during treatment (3.4%) compared to controls (7.1%) p<0.02.
	4. Software system to support pharmacists in caring for geriatric patients, designed to detect drug problems (DRPs). A retrospective analytical observational study was conducted at PKU Muhammadiyah Hospital and Sleman Hospital, Yogyakarta, in October–December 2014.⁸⁹	Pharmacy Decision Support System (PSS) effectively detects medication problems (DRPs) in elderly patients with 99% sensitivity and 60% specificity. PSS is superior to manual methods, especially in detecting incorrect doses, and provides more useful alerts for pharmacists.
	5. RCT design to assess the effectiveness of CDSS in reducing inappropriate prescribing in elderly patients in the ED, with the aim of reducing the risk of potentially inappropriate prescribing.⁹⁰	Research shows CDSS reduced inappropriate medication prescribing for elderly patients from 5.4% to 3.4%, with 43% of recommendations accepted. CPOE with CDSS significantly reduced potentially incorrect prescribing.
CDSS DRPs Psychiatric Patients	Computerized CPOE design with CDSS by pharmacists. A retrospective before-after cohort study in psychiatric inpatients with PCNE and NCC MERP classifications of DRPs.⁹¹	Findings: An average of 6 DRPs per patient, or 325 DRPs, were found in 54 patients. The most frequent DRP was inappropriate prescriptions at 34.8% which decreased significantly to 5.6% with a p value <0.001.
CDSS Medication Error ICU	1. CPOE with computerized medication error CDSS with prospective cohort design in ICU setting User: Pharmacist in UK.⁹²	The CPOE system with CDSS reduced medication errors from 6.7% to 4.8% (p<0.04) and continued to decline after implementation (p<0.001). CPOE with CDSS also identified three potentially fatal prescriptions and two errors that prolonged hospitalization.
	2. CDSS for medication errors: A pre- and post-intervention study in a 38-bed ICU with a sample of 47 before and 45 after the intervention. Errors analyzed included dose, route, and documentation. US study.⁹³	Implementation of CDSS and BCMA in the ICU reduced medication errors from 19.7% to 8.7% (p<0.001) and time errors from 18.8% to 7.5% (p<0.001), improving patient safety.
	3. CDSS study design on medication errors in ICU with pre-intervention and post-intervention methods, using random sampling: 2 ICUs in a hospital with an observation period of 4 months in France.⁹⁴	The treatment group reduced the risk of medication errors by 13.5%, lower than 18.6% in the control group (p<0.05). Medication errors were also lower (20.4% to 13.5%, p<0.01). CDSS reduced medication errors (p<0.05), with most errors being benign. Job quality improved from 1.0 to 2.5.
CDSS DRPs Inpatient	1. CDSS of potentially inappropriate drug prophylaxis (DRPs). Identifying and reducing DRPs through PIM Check (CDSS) with a prospective intervention study conducted on patients admitted to the internal medicine ward between September 1, 2015 and October 30, 2015.⁹⁵	A total of 909 DRPs were found in 297 patients, with 311 DRPs in the intervention group and 598 in the control group. The intervention group had an average of 2.9 DRPs per patient, compared to 3.2 DRPs in the control group (P=0.12). PIM-Check detected 33.4% of DRPs in the intervention group, but this did not reduce the number of DRPs.
	2. CDSS for high-alert medication (DRPs) with a prospective observational design was implemented for 9 months starting in January 2019 in two health facilities with a total of 1,000 beds, without a control group. CDSS users are Pharmacists in France.⁹⁶	Results: Of the total 1,508 alerts analyzed by pharmacists, 921 were Drug Related Problems (DRPs). Of the 540 alerts requiring pharmaceutical intervention, 219 were accepted and approved by physicians for follow-up.
	3. Pharmacist Alert Systems (PWS) or CDSS are automated systems that provide alerts about drug problems (DRPs). In 2012, PWS were integrated into the inpatient electronic medical record, including information on drug dosages, laboratory tests, and drug interactions.⁹⁷	Results: Over the course of the investigation, 2808 possible DRPs were found. Pharmacist intervention was necessary for 20% of the DRPs that PWS recognized as clinically significant.
	4. CDSS for drug therapy monitoring: A Dutch study compared a CDSS that checks patients' drug and medical history with standard care, aiming to reduce drug-related problems (DRPs).⁹⁸	CDSS influences the time required to take action to monitor patient therapy because the system displays DRPs, laboratory values, indications, and/or patient characteristics that can be accessed immediately. This makes the monitoring process more time efficient and allows therapy monitoring to be carried out at any time.
Other CDSS DRPs in ICU	1. CDSS in surgical patients: This RCT assessed the accuracy and severity of medication errors in a surgical ICU over 5 weeks with 22 patients. Users: Pharmacists in Canada.⁹⁹	During the observation, 9,414 alerts were generated, with an average of 2.5 alerts per month per participant. The most frequent alerts related to overdose (20%), drug constipation (13%), and kidney problems (12%). The success of the alert depended on the type of alert.
	2. CPOE with CDSS traumatic brain injury ICU prescription (drug interactions, allergies, doses and traumatic brain injury protocols. The study setting was an Adult ICU with all patients. Country: Saudi Arabia.¹⁰⁰	Mortality rates in the ICU and hospital did not differ significantly during the study. Use of a computerized medication ordering system (CPOE) and clinical decision support system (CDSS) did not affect the duration of mechanical ventilation, ICU, or hospital stay.
	3. CDSS on RBC transfusion algorithm in anemia (RBC transfusion algorithm). Duration 2 years in ICU United States.¹⁰¹	After the intervention, the mean number of red blood cell transfusions per patient decreased from 1.5 to 1.3 units (P = 0.045). Transfusion costs also decreased from $616,442 to $556,226. However, there was no significant change in length of stay or in-hospital mortality despite decreased transfusion rates and costs.

CONCLUSION:

Based on the results and discussions that have been obtained, it can be concluded that the impact of CDSS is very useful for identifying drug-related problems (DRPs) that help health workers, especially pharmacists, detect DRPs more quickly and accurately. Currently, there are still shortcomings in previous studies that comprehensively develop a medication monitoring system by pharmacists for patients based on Clinical Decision Support Systems (CDSS) for sepsis therapy. Sepsis therapy requires complex management including sepsis therapy, resuscitation fluids, vasopressors, corticosteroids, antimicrobials, glucose control agents, stress ulcer prophylaxis agents, blood transfusions, analgesics and sedatives, and anticoagulants. It is anticipated that the creation of an extensive CDSS system for this treatment will enhance patient clinical outcomes by facilitating prompt interventions and offering evidence-based suggestions that let pharmacists track the therapy's efficacy in real time and make the required modifications in response to the patient's clinical response.

CONFLICT OF INTEREST:

The authors have no conflict of interest regarding this investigation.

FUNDING:

This publication is sponsored by the Center for Higher Education Funding (BPPT) of the Ministry of Education, Culture, Research, and Technology of the Republic of Indonesia, under the Indonesian Education Scholarship Program (BPI) and the Indonesia Endowment Funds for Education (LPDP), Number: 02341/BPPT/BPI.06/9/2023.

ACKNOWLEDGEMENT:

The author would like to thank the lecturers and staff of the Doctoral Program in Pharmaceutical Sciences, Faculty of Pharmacy, Universitas Gadjah Mada, Yogyakarta, Indonesia, for their support in writing this journal. The author would also like to thank the Division of Pharmaceutical Publication, Universitas Gadjah Mada and Universitas Muhammadiyah Kalimantan Timur who have greatly assisted in writing the manuscript.

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Received on 03.11.2024 Revised on 13.03.2025

Accepted on 16.06.2025 Published on 01.10.2025

Available online from October 04, 2025

Research J. Pharmacy and Technology. 2025;18(10):5071-5080.

DOI: 10.52711/0974-360X.2025.00733

This work is licensed under a Creative Commons Attribution-NonCommercial-ShareAlike 4.0 International License. Creative Commons License.

No.	DRPs	Research Result
1.	Antibiotic acceptance in sepsis patients at X Hospital in Yogyakarta, Indonesia.³¹	As many as 60.49% of sepsis patients at Hospital X, Yogyakarta, Indonesia experienced DRPs in 2015. Antibiotic use, inappropriate administration, dosing errors, and interactions are the most common. 64.29% of DRPs were associated with worsening clinical outcomes.
2.	Hospital death rates are linked to excessive fluid accumulation in patients suffering from septic shock and severe sepsis.³²	67% of patients showed fluid overload on day 1 and 48% on day 3. Fluid overload was associated with higher mortality. There was a 0.7 weight gain in body weight & fluid overload.
3.	Inappropriate dosing puts elderly people in critical conditions—like sepsis patients with acute respiratory distress syndrome—at risk for negative drug reactions.³³	Hypoglycemia was observed in 131 cases with the use of sliding scale insulin. Inappropriate prescription (Beers criteria and Naranjo algorithm).
4.	The likehood of drug interactions in sepsis patients receiving therapy is becoming more severe.³⁴	1.84 ± 1.09 interactions/patient in 80% of 86 sepsis patients. 64.2% occurred in pharmacodynamics and 53.8% were documented completely, clearly, and reliably. The severity and onset were related to age & length of ICU stay.
5.	Studies in Sweden show that the high mortality rate in sepsis patients is related to delays in obtaining appropriate antibiotic therapy.³⁵	Inappropriate antibiotic treatment in 67 patients; delay in first dose in 63 cases. Mortality rate 3x higher if administration was delayed. 16% of patients experienced ADE (adverse drug events). 32% could be prevented from ADE.
6.	The development of medication related side effects during intensive care unit treatment.³⁶	16% of patients experienced an adverse drug event (ADE). 32% underwent ADE prevention.
7.	The prevalence of drug-induced nephrotoxic effects in intensive care unit patients.³⁷	13,492 ICU patients developed AKI, associated with nephrotoxic drugs including aminoglycosides, opioids, and others.
8.	DRPs in Intensive Care Unit on antibiotic therapy.³⁸	245 DRPs were found in the ICU during pharmaceutical interventions, most of which were ADEs (58.4%). Antibiotics caused 3/5 of the DRPs.
9.	One of the most prevalent drug-related issues in patients with sepsis is the requirement for further medication therapy.³⁹	71.51% of patients had drug-related problems. Common problems: need for further therapy (22.77%). Polypharmacy, longer treatment, and increased comorbidity are possible due to DRP.

Intensive Care Unit (ICU):

1. CDSS of potentially inappropriate drug prophylaxis (DRPs). Identifying and reducing DRPs through PIM Check (CDSS) with a prospective intervention study conducted on patients admitted to the internal medicine ward between September 1, 2015 and October 30, 2015.95

1. CDSS of potentially inappropriate drug prophylaxis (DRPs). Identifying and reducing DRPs through PIM Check (CDSS) with a prospective intervention study conducted on patients admitted to the internal medicine ward between September 1, 2015 and October 30, 2015.⁹⁵