Reduced Effectiveness of Interruptive Drug-Drug Interaction Alerts after Conversion to a Commercial Electronic Health Record

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Abstract

<div class="section"> <a class="named-anchor" id="d190927e218">  </a> <h5 class="section-title" id="d190927e219">Background</h5> <p id="Par1">Drug-drug interaction (DDI) alerts in electronic health records (EHRs) can help prevent adverse drug events, but such alerts are frequently overridden, raising concerns about their clinical usefulness and contribution to alert fatigue. </p> </div><div class="section"> <a class="named-anchor" id="d190927e223">  </a> <h5 class="section-title" id="d190927e224">Objective</h5> <p id="Par2">To study the effect of conversion to a commercial EHR on DDI alert and acceptance rates. </p> </div><div class="section"> <a class="named-anchor" id="d190927e228">  </a> <h5 class="section-title" id="d190927e229">Design</h5> <p id="Par3">Two before-and-after studies.</p> </div><div class="section"> <a class="named-anchor" id="d190927e233">  </a> <h5 class="section-title" id="d190927e234">Participants</h5> <p id="Par4">3277 clinicians who received a DDI alert in the outpatient setting.</p> </div><div class="section"> <a class="named-anchor" id="d190927e238">  </a> <h5 class="section-title" id="d190927e239">Intervention</h5> <p id="Par5">Introduction of a new, commercial EHR and subsequent adjustment of DDI alerting criteria.</p> </div><div class="section"> <a class="named-anchor" id="d190927e243">  </a> <h5 class="section-title" id="d190927e244">Main Measures</h5> <p id="Par6">Alert burden and proportion of alerts accepted.</p> </div><div class="section"> <a class="named-anchor" id="d190927e248">  </a> <h5 class="section-title" id="d190927e249">Key Results</h5> <p id="Par7">Overall interruptive DDI alert burden increased by a factor of 6 from the legacy EHR to the commercial EHR. The acceptance rate for the most severe alerts fell from 100 to 8.4%, and from 29.3 to 7.5% for medium severity alerts ( <i>P</i> < 0.001). After disabling the least severe alerts, total DDI alert burden fell by 50.5%, and acceptance of Tier 1 alerts rose from 9.1 to 12.7% ( <i>P</i> < 0.01). </p> </div><div class="section"> <a class="named-anchor" id="d190927e259">  </a> <h5 class="section-title" id="d190927e260">Conclusions</h5> <p id="Par8">Changing from a highly tailored DDI alerting system to a more general one as part of an EHR conversion decreased acceptance of DDI alerts and increased alert burden on users. The decrease in acceptance rates cannot be fully explained by differences in the clinical knowledge base, nor can it be fully explained by alert fatigue associated with increased alert burden. Instead, workflow factors probably predominate, including timing of alerts in the prescribing process, lack of differentiation of more and less severe alerts, and features of how users interact with alerts. </p> </div>

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Most cited references 29

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Effect of computerized physician order entry and a team intervention on prevention of serious medication errors.

David Bates (1998)

Adverse drug events (ADEs) are a significant and costly cause of injury during hospitalization. To evaluate the efficacy of 2 interventions for preventing nonintercepted serious medication errors, defined as those that either resulted in or had potential to result in an ADE and were not intercepted before reaching the patient. Before-after comparison between phase 1 (baseline) and phase 2 (after intervention was implemented) and, within phase 2, a randomized comparison between physician computer order entry (POE) and the combination of POE plus a team intervention. Large tertiary care hospital. For the comparison of phase 1 and 2, all patients admitted to a stratified random sample of 6 medical and surgical units in a tertiary care hospital over a 6-month period, and for the randomized comparison during phase 2, all patients admitted to the same units and 2 randomly selected additional units over a subsequent 9-month period. A physician computer order entry system (POE) for all units and a team-based intervention that included changing the role of pharmacists, implemented for half the units. Nonintercepted serious medication errors. Comparing identical units between phases 1 and 2, nonintercepted serious medication errors decreased 55%, from 10.7 events per 1000 patient-days to 4.86 events per 1000 (P=.01). The decline occurred for all stages of the medication-use process. Preventable ADEs declined 17% from 4.69 to 3.88 (P=.37), while nonintercepted potential ADEs declined 84% from 5.99 to 0.98 per 1000 patient-days (P=.002). When POE-only was compared with the POE plus team intervention combined, the team intervention conferred no additional benefit over POE. Physician computer order entry decreased the rate of nonintercepted serious medication errors by more than half, although this decrease was larger for potential ADEs than for errors that actually resulted in an ADE.

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Overriding of drug safety alerts in computerized physician order entry.

Heleen van der Sijs, Jos Aarts, Arnold Vulto … (2005)

Many computerized physician order entry (CPOE) systems have integrated drug safety alerts. The authors reviewed the literature on physician response to drug safety alerts and interpreted the results using Reason's framework of accident causation. In total, 17 papers met the inclusion criteria. Drug safety alerts are overridden by clinicians in 49% to 96% of cases. Alert overriding may often be justified and adverse drug events due to overridden alerts are not always preventable. A distinction between appropriate and useful alerts should be made. The alerting system may contain error-producing conditions like low specificity, low sensitivity, unclear information content, unnecessary workflow disruptions, and unsafe and inefficient handling. These may result in active failures of the physician, like ignoring alerts, misinterpretation, and incorrect handling. Efforts to improve patient safety by increasing correct handling of drug safety alerts should focus on the error-producing conditions in software and organization. Studies on cognitive processes playing a role in overriding drug safety alerts are lacking.