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Using Technology to Enhance Clozapine Prescribing Guidelines


Anne-Marie Osibajo ,

Richmond University Medical Center, US
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Safwa Zafar,

Richmond University Medical Center, US
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Gurkaron Nijjar,

Richmond University Medical Center, US
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Cathleen Gomez,

Richmond University Medical Center, US
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Nida Khan

Richmond University Medical Center
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How to Cite: Osibajo, A.-M., Zafar, S., Nijjar, G., Gomez, C. and Khan, N., 2019. Using Technology to Enhance Clozapine Prescribing Guidelines. Journal of Scientific Innovation in Medicine, 2(2), p.14. DOI:
  Published on 21 Aug 2019
 Accepted on 23 Jul 2019            Submitted on 23 Jul 2019


Clozapine is the most effective antipsychotic for the management of treatment-resistant schizophrenia [1], however, it continues to be under prescribed [1]. Adverse-effects of Clozapine, are one of the contributing factors leading to its low prescription rate [1], due the significant morbidity and mortality related to Clozapine. In order to monitor and prevent these complications, evidence based practice guidelines recommend dietary modifications, stool softeners and scheduled absolute neutrophil counts (ANC) [2]. In this study, we explore the effectiveness of how a Clozapine provider order sets (CPOS) in an Electronic Medical Records (EMR) system, improves compliance to evidence based practice guidelines; to ensure prevention of Clozapine adverse drug events, and thus, possibility increasing Clozapine use.


We utilized a multistep approach to explore the effectiveness of Clozapine order-sets. First, a Clozapine CPOS, which included: ordering ANC, stool softeners, and a high fiber diet, was implemented in Richmond University Medical Center’s (RUMC) EMR Software (Meditech) (Figure 1). Second, training was provided to prescribing physicians in the psychiatric department.

Figure 1 

Sample of the Clozapine Order Set implemented into the EMR System.

A retrospective study was conducted to quantitatively analyze Clozapine EMR data over an 18-month period (June 2017–December 2018).

A total of 112 records were retrieved. Twenty-three did not meet study criteria and were excluded. The no order set group was n = 50, with a mean age of 44.4 years; (44% female and 56% male). The order set group was n = 39, with a mean age of 41.2 years (61.5% female and 38.5% male) (Table 1).

Table 1

Demographical information of Study Population.

Pre-intervention group Post-intervention group Total

Mean Age 44.4 41,2 42.8
Female (%) 22 (44%) 24 (61.5%) 46 (51.7%)
Male 28 (56%) 15 (38.5%) 43 (48.3%)
n-value 50 39 89

We compared compliance of “order set” vs. “no order set” groups using logistic regression to determine the benefits of CPOS in our patient population. Adverse drug events was measured by the incidence of gastrointestinal hypo-motility [3], defined by the Constipation Assessment Scale (CAS). Criteria for data analysis included patients in the psychiatric department and who received >1 dose of Clozapine.


CPOS are effective in ensuring compliance with safe prescribing guidelines [95% CI 0.098–0.526, p = .0001].

Adverse drug events were reduced by 35.41% [95% CI 0.104–0.599; p = .005]. In the pre-intervention group, 52% of the patients experienced constipation while on the unit. Compared to only 15% in the post-intervention group (Figure 2).

Figure 2 

% of Constipation in Pre vs. Post Intervention Groups.

Figure 3 

Comparing Adverse Side Effects and Compliance with Evidence Based Guidelines in Pre and Post Interventional Groups.

After the CPOS intervention, the compliance of ordering: stool softeners increased from 32% to 91% (p < .0001); high fiber diet increased from 46%to 68% (p < .0001). The percentage of ordering weekly ANCs at the time of the first Clozapine order increased from 18% to 98% (p < .001).


Despite significant differences found when comparing the two groups, the current sample size remains small. Primarily, due to the implementation of the order set occurring less than a year ago. Future plans include conducting a similar study over a larger time period (+/–2 years from the intervention onset 2016–2020), about a 4-year span. In addition, future plans have been made to implement the CPOS order set throughout all departments at RUMC. Overall, including multiple departments, over a larger time period, will provide a larger sample size.

Compliance of the using the CPOS also varied. The highest occurrence of non-compliance happened in the first few months of new residency training (July–September). Efforts will be made to train incoming residents on the order-set during orientation and by email instructions; providing not only initial training of the PGY-1 class but retraining for senior classes (PGY 2–4) and attending prescribers.


Clozapine CPOS improve compliance with safe prescription guidelines, patient outcome and subsequently have the prospect to increase Clozapine prescription rates. More awareness of CPOS availability and expansion on the use of Clozapine CPOS in different departments at RUMC should be encouraged. Further studies are required to explore effective implementation of medication order sets, in the context of a larger process of patient care practice standards.


  1. Carruthers J, Radigan M, Erlich MD, et al. An initiative to improve clozapine prescribing in New York State. Psychiatric Services. 2015; 67(4): 369–371. 

  2. Hasan A. Clozapine-induced Gastrointestinal Hypomotility—New Objective Evidence for an Underestimated Side-effect. EBioMedicine. 2016; 5: 12–13. 

  3. Krive J, Shoolin JS and Zink SD. Effectiveness of evidence-based pneumonia CPOE order sets measured by health outcomes. Online journal of public health informatics. 2015; 7(2). 

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