Are we heeding the warning signs? Examining providers' overrides of computerized drug-drug interaction alerts in primary care.

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Abstract

Health IT can play a major role in improving patient safety. Computerized physician order entry with decision support can alert providers to potential prescribing errors. However, too many alerts can result in providers ignoring and overriding clinically important ones.

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Effects of computerized physician order entry and clinical decision support systems on medication safety: a systematic review.

Rainu Kaushal, Kaveh Shojania, David Bates (2003)

Iatrogenic injuries related to medications are common, costly, and clinically significant. Computerized physician order entry (CPOE) and clinical decision support systems (CDSSs) may reduce medication error rates. We identified trials that evaluated the effects of CPOE and CDSSs on medication safety by electronically searching MEDLINE and the Cochrane Library and by manually searching the bibliographies of retrieved articles. Studies were included for systematic review if the design was a randomized controlled trial, a nonrandomized controlled trial, or an observational study with controls and if the measured outcomes were clinical (eg, adverse drug events) or surrogate (eg, medication errors) markers. Two reviewers extracted all the data. Discussion resolved any disagreements. Five trials assessing CPOE and 7 assessing isolated CDSSs met the criteria. Of the CPOE studies, 2 demonstrated a marked decrease in the serious medication error rate, 1 an improvement in corollary orders, 1 an improvement in 5 prescribing behaviors, and 1 an improvement in nephrotoxic drug dose and frequency. Of the 7 studies evaluating isolated CDSSs, 3 demonstrated statistically significant improvements in antibiotic-associated medication errors or adverse drug events and 1 an improvement in theophylline-associated medication errors. The remaining 3 studies had nonsignificant results. Use of CPOE and isolated CDSSs can substantially reduce medication error rates, but most studies have not been powered to detect differences in adverse drug events and have evaluated a small number of "homegrown" systems. Research is needed to evaluate commercial systems, to compare the various applications, to identify key components of applications, and to identify factors related to successful implementation of these systems.

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Adverse drug events in ambulatory care.

Tejal Gandhi, Saul N Weingart, Joshua Borus … (2003)

Adverse events related to drugs occur frequently among inpatients, and many of these events are preventable. However, few data are available on adverse drug events among outpatients. We conducted a study to determine the rates, types, severity, and preventability of such events among outpatients and to identify preventive strategies. We performed a prospective cohort study, including a survey of patients and a chart review, at four adult primary care practices in Boston (two hospital-based and two community-based), involving a total of 1202 outpatients who received at least one prescription during a four-week period. Prescriptions were computerized at two of the practices and handwritten at the other two. Of the 661 patients who responded to the survey (response rate, 55 percent), 162 had adverse drug events (25 percent; 95 percent confidence interval, 20 to 29 percent), with a total of 181 events (27 per 100 patients). Twenty-four of the events (13 percent) were serious, 51 (28 percent) were ameliorable, and 20 (11 percent) were preventable. Of the 51 ameliorable events, 32 (63 percent) were attributed to the physician's failure to respond to medication-related symptoms and 19 (37 percent) to the patient's failure to inform the physician of the symptoms. The medication classes most frequently involved in adverse drug events were selective serotonin-reuptake inhibitors (10 percent), beta-blockers (9 percent), angiotensin-converting-enzyme inhibitors (8 percent), and nonsteroidal antiinflammatory agents (8 percent). On multivariate analysis, only the number of medications taken was significantly associated with adverse events. Adverse events related to drugs are common in primary care, and many are preventable or ameliorable. Monitoring for and acting on symptoms are important. Improving communication between outpatients and providers may help prevent adverse events related to drugs. Copyright 2003 Massachusetts Medical Society

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Physicians' decisions to override computerized drug alerts in primary care.

D Aronson, Mária Tóth, Christopher B Davis … (2003)

Although computerized physician order entry reduces medication errors among inpatients, little is known about the use of this system in primary care. We calculated the override rate among 3481 consecutive alerts generated at 5 adult primary care practices that use a common computerized physician order entry system for prescription writing. For detailed review, we selected a random sample of 67 alerts in which physicians did not prescribe an alerted medication and 122 alerts that resulted in a written prescription. We identified factors associated with the physicians' decisions to override a medication alert, and determined whether an adverse drug event (ADE) occurred. Physicians overrode 91.2% of drug allergy and 89.4% of high-severity drug interaction alerts. In the multivariable analysis using the medical chart review sample (n = 189), physicians were less likely to prescribe an alerted medication if the prescriber was a house officer (odds ratio [OR], 0.26; 95% confidence interval [CI], 0.08-0.84) and if the patient had many drug allergies (OR, 0.70; 95% CI, 0.53-0.93). They were more likely to override alerts for renewals compared with new prescriptions (OR, 17.74; 95% CI, 5.60-56.18). We found no ADEs in cases where physicians observed the alert and 3 ADEs among patients with alert overrides, a nonsignificant difference (P =.55). Physician reviewers judged that 36.5% of the alerts were inappropriate. Few physicians changed their prescription in response to a drug allergy or interaction alert, and there were few ADEs, suggesting that the threshold for alerting was set too low. Computerized physician order entry systems should suppress alerts for renewals of medication combinations that patients currently tolerate.

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Journal

Journal ID (iso-abbrev): PLoS ONE

Title: PloS one

Publisher: Public Library of Science (PLoS)

ISSN (Electronic): 1932-6203

ISSN (Print): 1932-6203

Publication date (Electronic): 2013

Volume: 8

Issue: 12

Affiliations

[1 ] The Center for Patient Safety Research and Practice, Division of General Internal Medicine, Brigham and Women's Hospital, Boston, Massachusetts, United States of America ; School of Medicine, Pharmacy and Health, The University of Durham, Stockton on Tees, Durham, United Kingdom ; Harvard Medical School, Boston, Massachusetts, United States of America.

[2 ] Partners Healthcare Systems, Inc., Wellesley, Boston, Massachusetts, United States of America.

[3 ] Harvard Medical School, Boston, Massachusetts, United States of America ; Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Boston, Massachusetts, United States of America.

[4 ] The Center for Patient Safety Research and Practice, Division of General Internal Medicine, Brigham and Women's Hospital, Boston, Massachusetts, United States of America ; Harvard Medical School, Boston, Massachusetts, United States of America ; Nursing Department, Inha University, Incheon, South Korea.

[5 ] The Center for Patient Safety Research and Practice, Division of General Internal Medicine, Brigham and Women's Hospital, Boston, Massachusetts, United States of America ; Partners Healthcare Systems, Inc., Wellesley, Boston, Massachusetts, United States of America.

[6 ] The Center for Patient Safety Research and Practice, Division of General Internal Medicine, Brigham and Women's Hospital, Boston, Massachusetts, United States of America ; Harvard Medical School, Boston, Massachusetts, United States of America ; Partners Healthcare Systems, Inc., Wellesley, Boston, Massachusetts, United States of America.

Article

Publisher Item ID: PONE-D-13-22969

DOI: 10.1371/journal.pone.0085071

PMC ID: 3873469

PubMed ID: 24386447

SO-VID: 5f689647-1781-419a-92f4-c2612df16d33

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Are we heeding the warning signs? Examining providers' overrides of computerized drug-drug interaction alerts in primary care.

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PLOS Climate

Most cited references 12

Effects of computerized physician order entry and clinical decision support systems on medication safety: a systematic review.

Adverse drug events in ambulatory care.

Physicians' decisions to override computerized drug alerts in primary care.

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Cited by 22

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