Association Between Real-Time Alerts in Electronic Prescribing Systems and Potentially Inappropriate Prescribing Among Older Adults

BACKGROUND: Older adults are highly susceptible to adverse effects from potentially inappropriate medications (PIMs). Real-time clinical decision support systems (CDSS) may reduce unsafe prescribing; yet evidence from low- and middle-income countries is limited. This study assessed the association between a national electronic alert system and outpatient PIM prescribing in Iran. METHODS: We examined 230,719 electronic outpatient prescriptions for adults aged 65 years and older. Prescriptions from May to August 2023 (pre-alert) were compared with those from May to August 2024 (post-alert). The primary outcome was the proportion of prescriptions containing ≥ 1 PIM, defined using the 2023 AGS Beers Criteria. Subgroup analyses stratified outcomes by age, sex, physician specialty, and drug class. RESULTS: Across 2023-2024, 230,719 prescriptions were recorded. After alert implementation, the greatest reductions occurred in adults aged 85-100 years (-9.85%) and in women (-7.89%). Significant declines were also observed in gastrointestinal drugs (-14.14%), pain medications (-11.99%), central nervous system agents (-3.03%), antihistamines (-4.60%), and in specific medications including ketorolac, clidinium-chlordiazepoxide, methocarbamol, nortriptyline, chlorpheniramine, indomethacin, and dicyclomine. By specialty, the largest reductions were seen in Surgery (-18.13%), Internal Medicine (-12.56%), and General Practice (-6.99%). CONCLUSIONS: A national, real-time, non-interruptive alert system was associated with meaningful reductions in PIM prescribing among older adults. Scalable CDSS tools may enhance medication safety in resource-constrained settings.