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Background and Importance Adverse drug events (ADEs) can result in severe patient harm or even death. Antithrombotics are frequently implicated in (fatal) ADEs. In Dutch pharmacies, computerised decision support systems (CDSS) generate medication safety alerts to help prevent ADEs. However, current CDSS have low specificity. The extent to which this hampers CDSS efficiency remains largely unexplored in hospital-based outpatient and community pharmacies.Aim and Objectives To determine the proportion of CDSS alerts on antithrombotics and any medication that result in an intervention in Dutch hospital-based outpatient pharmacies and community pharmacies.Material and Methods A multicentre, single-day, cross-sectional observational study was conducted using a flashmob design. All hospital-based outpatient and community pharmacies in the Netherlands were invited to participate. Pharmacy staff collected the number and type of CDSS alerts on antithrombotics and on any medication, the number of performed interventions, and the estimated time spent on assessing alert relevance. An intervention was defined as an action in response to an alert (eg, call physician, educate patient). The primary outcome was the efficiency of alerts on antithrombotics, defined as the proportion of alerts needing an intervention. Secondary outcomes included the efficiency of alerts on any medication, the efficiency per alert type and the estimated time spent on assessing the alert relevance. Descriptive statistics were used for data analysis.Results Of the 2004 pharmacies invited (76 outpatient, 1928 community), 82 pharmacies participated (response rate 4.1%). Eventually, 80 pharmacies (32 outpatient, 50 community) were included. A total of 2,463 antithrombotic alerts were reported (median 25 per pharmacy, interquartile range (IQR) 42) and 36,508 alerts for any medication (median 382 per pharmacy, IQR 369). CDSS efficiency was 0.0% (IQR 2.4%) for antithrombotic alerts and 1.9% (IQR 2.9%) for alerts on any medication. For alerts on any medication, drug-drug interaction alerts showed the highest efficiency (4.0%, IQR 9.5%). The estimated time spent on assessing alert relevance was almost 2 hours per pharmacy (01:54h, IQR 01:38).Conclusion and Relevance This study shows that the efficiency of CDSS alerts on both antithrombotics and on any medication is very low in hospital-based outpatient and community pharmacies. Optimisation of CDSS efficiency is necessary to improve efficiency and patient safety in hospitals and primary care.Conflict of Interest No conflict of interest