Planejamento e integração de alertas de dose máxima em sistema eletrônico de prescrição como ferramenta de suporte à decisão clínica

• DOI: https://doi.org/10.22533/at.ed.011112620016

• Palavras-chave: Segurança do paciente; Erros de medicação; Prescrição eletrônica.

• Keywords: Patient safety; Medication errors; Electronic prescribing.

• Abstract: High-alert medications pose an increased risk of causing serious harm when used incorrectly. Electronic prescribing systems are essential tools to reduce these risks by providing more precise dose control and notifications regarding inconsistencies. In this context, implementing maximum and minimum dose alerts is an important strategy to ensure prescriptions remain within safe limits and to minimize medication errors. This study aimed to report the Volume X, Número X, 20XX 3 implementation of maximum dose alerts for high-alert medications in an electronic prescribing system. Between September 2024 and June 2025, an initiative was developed in a high-complexity university hospital in Rio de Janeiro to create and implement these alerts. Medications were selected according to the ISMP Brazil list and the criteria established by the Patient Safety Center. Maximum doses were defined based on references such as Micromedex, UpToDate, Neofax Pediatrics, Cognys Med, and Whitebook, and were consolidated into a spreadsheet. Informational alerts were developed for three age groups (neonates, children and adolescents, and adults) triggering a notification to the prescriber whenever the dose exceeded the recommended limit, without blocking the prescription. A total of 265 alerts were developed: 57 for neonates, 99 for children and adolescents, and 109 for adults, covering 110 medication presentations and 89 substances. All alerts were integrated into the institution’s electronic system. This experience highlights the relevance of clinical decision-support technologies and demonstrates the potential of this initiative to prevent prescribing errors, strengthen safe practices, and enhance medication-use safety in the hospital setting.