Medication-related Alerts Research Articles

Evaluation of appropriateness of alerts overrides and physicians' responses of the medication-related clinical decision support system in China, a hospital-based study.

This study was designed to investigate the state quo of the appropriateness of alerts overrides of the medication-related clinical decision support system (MRCDSS) in China. The medication-related alerts in one hospital from Jan 2022 to Dec 2022 were acquired and sampled. Rates of alert overrides, appropriateness of alert generation and physicians' responses were observed. Total 14,612 medication-related alerts (≤ level 3) were recorded, of those, 12,659 (86.6%) alerts were overridden. The top 3 alert types were: drug and diagnosis contraindications (23.8%), drug and test value contraindications (23.3%), and compatibility issues (17.7%). Of all sampled 1,501 alerts, 80.2% of them were appropriately overridden by the physicians. The appropriate rate of alert generation was 57.9% and the inappropriate rate was 42.1%. The inappropriate rate of physicians' responses was 17.8%, and 2.0% physicians' responses were undetermined. A few medications accounted for over 10% of overrides, 88.3% of "overridden reasons" inputted by the physicians were meaningless characters or values, indicating an obvious "alert fatigue" in these physicians. Our results indicated that the overridden rate of MRCDSS in China was still high, and appropriateness of generation of alert was quite low. These data indicated that the MRCDSS currently using in China still needs constantly optimization and timely maintenance. Proper sensitivity to reduce triggering of useless alerts and generation of alert fatigue might play a vital role. We believed that these findings are helpful for better understanding the state quo of MRCDSS in China and providing useful insights for future developing and improving MRCDSS.

Retrospective descriptive assessment of clinical decision support medication-related alerts in two Saudi Arabian hospitals

ObjectivesTo determine the frequency of clinical decision support system (CDSS) medication-related alerts generated, accepted, or overridden, to assess appropriateness of alert display and overrides, and to characterise the documentation of clinician justification for these overrides in an academic medical centre in Saudi Arabia.Materials and methodsSystem-generated CDSS reports for the period June 2015 to December 2017 were retrospectively reviewed and analysed. Alerts were classified into different types, and rates of alert overrides calculated as percentages of all generated alerts. A subset of 307 overridden alerts was assessed for appropriateness of display and override by two clinical pharmacists. Physician documentation of reasons for overriding alerts were categorised.ResultsA total of 4,446,730 medication-related alerts were generated from both inpatient and outpatient settings, and 4,231,743 (95.2%) were overridden. The most common alert type was ‘duplicate drug’, accounting for 3,549,736 (79.8%) of alerts. Of 307 alerts assessed for appropriateness, 246 (80%) were judged to be appropriately displayed and 244 (79%) were overridden appropriately. New drug allergy and drug allergy alerts had the highest percentage of being judged as inappropriately overridden. For 1,594,313 alerts (37.7%), ‘no overridden reason selected’ was chosen from the drop-down menu.ConclusionsThe alert generation and override rate were higher than reported previously in the literature. The small sample size of 307 alerts assessed for appropriateness of alert display and override is a potential limitation. Revision of the CDSS rules for alerts (focusing on specificity and relevance for the local context) is now recommended. Future research should prospectively assess providers’ perspectives, and determine patient harm associated with overridden alerts.

Medication Errors and Patient Safety: Evaluation of Physicians' Responses to Medication-Related Alert Overrides in Clinical Decision Support Systems.

Background:Clinical decision support systems (CDSS) can enhance patient safety and reduce medication errors by giving physicians alerts while dispensing medications. Physicians inappropriately override these alerts for various reasons, which can possibly lead to medication errors and impact patient safety.Objective:To assess the appropriateness of overridden major medication-related alerts, to investigate the reasons behind inappropriate overriding, and to evaluate if medication errors occur in inappropriately overridden alerts.Methods:A mixed-methods study was conducted.. Quantitative: Retrospective observation to evaluate the appropriateness of major drug-dose related alert overrides. A simple random sample was taken from appropriate and inappropriate overrides and reviewed for medication errors. Qualitative: Semi-Structured Interviews were conducted with ten consultant physicians from various specialties. Interviews were transcribed and coded inductively then analyzed using Thematic Content Analysis.Results:Out of 1087 alert overrides that were evaluated for appropriateness, 738 were inappropriately overridden (67.89%). In a sample of 283 inappropriate and 92 appropriate overrides; the resulted medication errors were 7 and 0, respectively. Qualitative analysis resulted in three emergent themes; Judgement, Experience & Guidelines, CDSS Issues & Limitations, Physician Behavior & Safety.Conclusion:The majority of alerts were found to be inappropriately overridden. This can be attributed to physician reliance on their clinical knowledge and medication databases, having the pharmacists’ checks, and alert fatigue. CDSS alerts can be improved by making them more prominent and suppressing or descaling unnecessary alerts. The drop-down justification list can be enhanced by adding free text options and relating recommended dosing to disease or specialty.

A Late Attempt to Involve End Users in the Design of Medication-Related Alerts: Survey Study.

BackgroundWhen users of electronic medical records (EMRs) are presented with large numbers of irrelevant computerized alerts, they experience alert fatigue, begin to ignore alert information, and override alerts without processing or heeding alert recommendations. Anecdotally, doctors at our study site were dissatisfied with the medication-related alerts being generated, both in terms of volume being experienced and clinical relevance.ObjectiveThis study aimed to involve end users in the redesign of medication-related alerts in a hospital EMR, 4 years post implementation.MethodsThis work was undertaken at a private not-for-profit teaching hospital in Sydney, Australia. Since EMR implementation in 2015, the organization elected to implement all medication-related alert types available in the system for prescribers: allergy and intolerance alerts, therapeutic duplication alerts, pregnancy alerts, and drug-drug interaction alerts. The EMR included no medication administration alerts for nurses. To obtain feedback on current alerts and suggestions for redesign, a Web-based survey was distributed to all doctors and nurses at the site via hospital mailing lists.ResultsDespite a general dissatisfaction with alerts, very few end users completed the survey. In total, only 3.37% (36/1066) of doctors and 14.5% (60/411) of nurses took part. Approximately 90% (30/33) of doctors who responded held the view that too many alerts were triggered in the EMR. Doctors suggested that most alerts be removed and that alerts be more specific and less sensitive. In contrast, 97% (58/60) of the nurse respondents indicated that they would like to receive medication administration alerts in the EMR. Most nurses indicated that they would like to receive all the alert types available at all severity levels.ConclusionsAttempting to engage with end users several years post implementation was challenging. Involving users so late in the implementation process may lead to clinicians viewing the provision of feedback to be futile. Seeking user feedback on usefulness, volume, and design of alerts is extremely valuable; however, we suggest this is undertaken early, preferably before system implementation.

The national cost of adverse drug events resulting from inappropriate medication-related alert overrides in the United States.

To estimate the national cost of ADEs resulting from inappropriate medication-related alert overrides in the U.S. inpatient setting. We used three different regression models (Basic, Model 1, Model 2) with model inputs taken from the medical literature. A random sample of 40 990 adult inpatients at the Brigham and Women's Hospital (BWH) in Boston with a total of 1 639 294 medication orders was taken. We extrapolated BWH medication orders using 2014 National Inpatient Sample (NIS) data. Using three regression models, we estimated that 29.7 million adult inpatient discharges in 2014 resulted in between 1.02 billion and 1.07 billion medication orders, which in turn generated between 75.1 million and 78.8 million medication alerts, respectively. Taking the basic model (78.8 million), we estimated that 5.5 million medication-related alerts might have been inappropriately overridden, resulting in approximately 196 600 ADEs nationally. This was projected to cost between $871 million and $1.8 billion for treating preventable ADEs. We also estimated that clinicians and pharmacists would have jointly spent 175 000 hours responding to 78.8 million alerts with an opportunity cost of $16.9 million. These data suggest that further optimization of hospitals computerized provider order entry systems and their associated clinical decision support is needed and would result in substantial savings. We have erred on the side of caution in developing this range, taking two conservative cost estimates for a preventable ADE that did not include malpractice or litigation costs, or costs of injuries to patients.

Evaluation of medication-related clinical decision support alert overrides in the intensive care unit

PurposeMedication-related clinical decision support (CDS) has been identified as a method to improve patient outcomes but is historically frequently overridden and may be inappropriately so. Patients in the intensive care unit (ICU) are at a higher risk of harm from adverse drug events (ADEs) and these overrides may increase patient harm. The objective of this study is to determine appropriateness of overridden medication-related CDS overrides in the ICU. Materials and methodsWe evaluated overridden medication-related alerts of four alert categories from January 2009 to December 2011. The primary outcome was the appropriateness of a random sample of overrides based on predetermined criteria. Secondary outcomes included the incidence of adverse drug events (ADEs) that resulted from the overridden alert. ResultsA total of 47,449 overridden alerts were included for evaluation. The appropriateness rate for overridden alerts varied by alert category (allergy: 94%, drug-drug interaction: 84%, geriatric: 57%, renal: 27%). A total of seven actual ADEs were identified in the random sample and where the medication(s) was administered (n=366), with an increased risk of ADEs associated with inappropriately overridden alerts (p=0.0078). ConclusionsThe appropriateness of medication-related clinical decision support overrides in the ICU varied substantially by the type of alert. Inappropriately overridden alerts were associated with an increased risk of ADEs compared to appropriately overridden alerts.

Clinical decision support for atypical orders: detection and warning of atypical medication orders submitted to a computerized provider order entry system

The specificity of medication-related alerts must be improved to overcome the pernicious effects of alert fatigue. A systematic comparison of new drug orders to historical orders could improve alert specificity and relevance. Using historical order data from a computerized provider order entry system, we alerted physicians to atypical orders during the prescribing of five medications: calcium, clopidogrel, heparin, magnesium, and potassium. The percentage of atypical orders placed for these five medications decreased during the 92 days the alerts were active when compared to the same period in the previous year (from 0.81% to 0.53%; p=0.015). Some atypical orders were appropriate. Fifty of the 68 atypical order alerts were over-ridden (74%). However, the over-ride rate is misleading because 28 of the atypical medication orders (41%) were changed. Atypical order alerts were relatively few, identified problems with frequencies as well as doses, and had a higher specificity than dose check alerts.

Commentary: The Role of “Technovigilance” in Improving Care in Hospitals

Commentary: The Role of “Technovigilance” in Improving Care in Hospitals

Towards Meaningful Medication-Related Clinical Decision Support: Recommendations for an Initial Implementation

Clinical decision support (CDS) can improve safety, quality, and cost-effectiveness of patient care, especially when implemented in computerized provider order entry (CPOE) applications. Medication-related decision support logic forms a large component of the CDS logic in any CPOE system. However, organizations wishing to implement CDS must either purchase the computable clinical content or develop it themselves. Content provided by vendors does not always meet local expectations. Most organizations lack the resources to customize the clinical content and the expertise to implement it effectively. In this paper, we describe the recommendations of a national expert panel on two basic medication-related CDS areas, specifically, drug-drug interaction (DDI) checking and duplicate therapy checking. The goals of this study were to define a starter set of medication-related alerts that healthcare organizations can implement in their clinical information systems. We also draw on the experiences of diverse institutions to highlight the realities of implementing medication decision support. These findings represent the experiences of institutions with a long history in the domain of medication decision support, and the hope is that this guidance may improve the feasibility and efficiency CDS adoption across healthcare settings.