Clinical Safety Issue - Incorrect Interaction Severity Level for Certain Drug Pairings (Vision 3)
Cegedim Healthcare Solutions has been made aware of an issue where some major interactions will not display in Vision 3 if a Vision user has set up Vision to only display interaction warnings of severity 'severe and major only'.
This is due to a situation where major interactions between certain drug pairs are incorrectly being listed as minor interactions in the version of the Vision interactions file that is used by Vision 3 to provide information regarding drug interactions, including informing on their severity rating.
Affected major interactions will only display in Vision 3 if a Vision user has selected for interaction warnings of severity 'severe, major and minor’ to be displayed.
This presents a clinical safety risk with implications for patient care that may have adverse consequences for the patient concerned as the prescriber will not see warnings for the affected drug pairings. As an example, the pairing of Allopurinol and Azathioprine is one of the affected major interactions. The interaction warning in Vision 3 suggests reducing Azathioprine dose when taken together with Allopurinol. Where this interaction warning is missed, this may result in a patient being on a higher than needed dose of Azathioprine.
The following, attached file lists drug pair interactions where this issue may occur (see 'How-To' worksheet for details).
Note that, when displayed in Vision, interaction warnings for the affected drug pairings will be displayed at the correct level of interaction severity (i.e. they will display in Vision as major interaction warnings), however these will only be picked up for display where interaction warnings of severity 'severe, major and minor’ have been selected to be displayed.
This issue will be fully resolved via the rollout of the next (November) drug data update.
In the meantime, as interim mitigation against the associated clinical safety risk, we would ask that all practices ensure that their Vision system is set up to display interaction warnings of severity 'severe, major and minor’ to ensure visibility of the affected warnings. See here for guidance on how to set up Vision in this way.
Cegedim Healthcare Solutions apologises for any inconvenience caused.
Many thanks for your co-operation with this matter.
If you require any further information, please contact the Cegedim UK Clinical Safety Team at clinical.safety@visionhealth.co.uk.