Factors associated with medication warning acceptance for hospitalized adults

A systematic review of drug allergy alert systems

BACKGROUND AND OBJECTIVE

Drug allergy alert systems (DAAS), have been considered an effective strategy to reduce preventable adverse drug events (ADEs), improving patient's safety. To date, no review has been conducted analyzing characteristics of DAAS in the hospital setting. Therefore, the aim of this study is to identify, describe and summarize the DAAS used in hospitals. The secondary objectives are to analyse drug allergy alerts (DAA) characteristics, the override rate (OvR) and the clinical consequences of alert overrides.

METHODS

Searches were conducted in Medline and Cochrane Library to identify studies describing DAAS. Systems characteristics, generated alerts, DAA, OvR, and its clinical consequences were extracted and analyzed.

RESULTS

Twenty-eight articles were included in the review. Seventeen different electronic DAAS were identified, of which 53% were commercially available. Systems differed in drug allergy information and rules for generating alerts. DAA were generally interruptive, triggered by non-exact match at drug prescribing and when ignored, an override reason was mandatory. The OvR ranged from 43.7% to 97%. The main override reason given by providers was that 'patient had previously tolerated or had taken the drug without allergic reaction'. Clinical consequences of overriding DAA were only analyzed in four studies, with an ADE incidence between 0% and 6%.

CONCLUSIONS

Different DAAS are used in hospitals with some degree of heterogeneity. Accurate and updated drug allergy information is important to generate only high value alerts. A regular review of DAAS and a standardization of alert rules, alert information and override reasons are necessary to optimize systems. Future studies should evaluate the impact of the DAAS aspects on preventing ADEs.

Drug Alert Experience and Salience during Medical Residency at Two Healthcare Institutions

BACKGROUND

Drug alerts are clinical decision support tools intended to prevent medication misadministration. In teaching hospitals, residents encounter the majority of the drug alerts while learning under variable workloads and responsibilities that may have an impact on drug-alert response rates.

OBJECTIVES

This study was aimed to explore drug-alert experience and salience among postgraduate year 1 (PGY-1), postgraduate year 2 (PGY-2), and postgraduate year 3 (PGY-3) internal medicine resident physicians at two different institutions.

METHODS

Drug-alert information was queried from the electronic health record (EHR) for 47 internal medicine residents at the University of Pennsylvania Medical Center (UPMC) Pinnacle in Pennsylvania, and 79 internal medicine residents at the MetroHealth System (MHS) in Ohio from December 2018 through February 2019. Salience was defined as the percentage of drug alerts resulting in removal or modification of the triggering order. Comparisons were made across institutions, residency training year, and alert burden.

RESULTS

A total of 126 residents were exposed to 52,624 alerts over a 3-month period. UPMC Pinnacle had 15,574 alerts with 47 residents and MHS had 37,050 alerts with 79 residents. At MHS, salience was 8.6% which was lower than UPMC Pinnacle with 15%. The relatively lower salience (42% lower) at MHS corresponded to a greater number of alerts-per-resident (41% higher) compared with UPMC Pinnacle. Overall, salience was 11.6% for PGY-1, 10.5% for PGY-2, and 8.9% for PGY-3 residents.

CONCLUSION

Our results are suggestive of long-term drug-alert desensitization during progressive residency training. A higher number of alerts-per-resident correlating with a lower salience suggests alert fatigue; however, other factors should also be considered including differences in workload and culture.

Medication safety alert fatigue may be reduced via interaction design and clinical role tailoring: a systematic review

OBJECTIVE

Alert fatigue limits the effectiveness of medication safety alerts, a type of computerized clinical decision support (CDS). Researchers have suggested alternative interactive designs, as well as tailoring alerts to clinical roles. As examples, alerts may be tiered to convey risk, and certain alerts may be sent to pharmacists. We aimed to evaluate which variants elicit less alert fatigue.

MATERIALS AND METHODS

We searched for articles published between 2007 and 2017 using the PubMed, Embase, CINAHL, and Cochrane databases. We included articles documenting peer-reviewed empirical research that described the interactive design of a CDS system, to which clinical role it was presented, and how often prescribers accepted the resultant advice. Next, we compared the acceptance rates of conventional CDS-presenting prescribers with interruptive modal dialogs (ie, "pop-ups")-with alternative designs, such as role-tailored alerts.

RESULTS

Of 1011 articles returned by the search, we included 39. We found different methods for measuring acceptance rates; these produced incomparable results. The most common type of CDS-in which modals interrupted prescribers-was accepted the least often. Tiering by risk, providing shortcuts for common corrections, requiring a reason to override, and tailoring CDS to match the roles of pharmacists and prescribers were the most common alternatives. Only 1 alternative appeared to increase prescriber acceptance: role tailoring. Possible reasons include the importance of etiquette in delivering advice, the cognitive benefits of delegation, and the difficulties of computing "relevance."

CONCLUSIONS

Alert fatigue may be mitigated by redesigning the interactive behavior of CDS and tailoring CDS to clinical roles. Further research is needed to develop alternative designs, and to standardize measurement methods to enable meta-analyses.

Electronic clinical decision support to facilitate a change in clinical practice: Small details can make or break success

BACKGROUND

The use of electronic clinical decision support (CDS) is becoming common to change historically common clinical practices considered outdated by current guidelines. Preimplementation design of CDS tools is key to their success in changing clinical behaviors. Unfortunately, there are no established protocols for CDS tool development, and CDS failure can result from even small design flaws. This paper describes an example of a design oversight and how correction resulted in CDS success.

STUDY DESIGN AND METHODS

We performed a retrospective review of compliance with a CDS tool to encourage the use of prothrombin complex concentrate over plasma transfusion for the emergent reversal of warfarin. We identified a potential design flaw, made the necessary modifications, and repeated the compliance review.

RESULTS

After CDS, plasma orders declined by 150 units/mo; however, 48% of orders placed for non-warfarin coagulopathy were still for warfarin reversal. Hospital-wide, this noncompliance was 36% and was 80% in the emergency department. By simply relocating the qualifier "NOT on warfarin" from the end to the beginning of the order, noncompliance for warfarin reversal was reduced to 5% (P < .0001 by chi-square).

CONCLUSIONS

The successful use of electronic clinical decision support in the electronic medical record can depend on optimal design. Missing even small design elements such as the positioning of key terms within the tool can result in an ineffective CDS. Important design strategies to avoid poor performance are discussed as they relate to the CDS tool we describe.

The Effect of Eliminating Intermediate Severity Drug-Drug Interaction Alerts on Overall Medication Alert Burden and Acceptance Rate

OBJECTIVE

This study aimed to determine the effects of reducing the number of drug-drug interaction (DDI) alerts in an order entry system.

METHODS

Retrospective pre-post analysis at an urban medical center of the rates of medication alerts and alert acceptance during a 5-month period before and 5-month period after the threshold for firing DDI alerts was changed from "intermediate" to "severe." To ensure that we could determine varying response to each alert type, we took an in-depth look at orders generating single alerts.

RESULTS

Before the intervention, 241,915 medication orders were placed, of which 25.6% generated one or more medication alerts; 5.3% of the alerts were accepted. During the postintervention period, 245,757 medication orders were placed of which 16.0% generated one or more medication alerts, a 37.5% relative decrease in alert rate (95% confidence interval [CI]: -38.4 to -36.8%), but only a 9.6% absolute decrease (95% CI: -9.4 to -9.9%). 7.4% of orders generating alerts were accepted postintervention, a 39.6% relative increase in acceptance rate (95% CI: 33.2-47.2%), but only a 2.1% absolute increase (95% CI: 1.8-2.4%). When only orders generating a single medication alert were considered, there was a 69.1% relative decrease in the number of orders generating DDI alerts, and an 85.7% relative increase in the acceptance rate (95% CI: 58.6-126.2%), though only a 1.8% absolute increase (95% CI: 1.3-2.3%).

CONCLUSION

Eliminating intermediate severity DDI alerts resulted in a statistically significant decrease in alert burden and increase in the rate of medication alert acceptance, but alert acceptance remained low overall.

Clinical Decision Support Systems for Drug Allergy Checking: Systematic Review

BACKGROUND

Worldwide, the burden of allergies-in particular, drug allergies-is growing. In the process of prescribing, dispensing, or administering a drug, a medication error may occur and can have adverse consequences; for example, a drug may be given to a patient with a documented allergy to that particular drug. Computerized physician order entry (CPOE) systems with built-in clinical decision support systems (CDSS) have the potential to prevent such medication errors and adverse events.

OBJECTIVE

The aim of this review is to provide a comprehensive overview regarding all aspects of CDSS for drug allergy, including documenting, coding, rule bases, alerts and alert fatigue, and outcome evaluation.

METHODS

The Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines were followed as much as possible and searches were conducted in 5 databases using CPOE, CDSS, alerts, and allergic or allergy as keywords. Bias could not be evaluated according to PRISMA guidelines due to the heterogeneity of study types included in the review.

RESULTS

Of the 3160 articles considered, 60 met the inclusion criteria. A further 9 articles were added based on expert opinion, resulting in a total of 69 articles. An interrater agreement of 90.9% with a reliability Κ=.787 (95% CI 0.686-0.888) was reached. Large heterogeneity across study objectives, study designs, study populations, and reported results was found. Several key findings were identified. Evidence of the usefulness of clinical decision support for drug allergies has been documented. Nevertheless, there are some important problems associated with their use. Accurate and structured documenting of information on drug allergies in electronic health records (EHRs) is difficult, as it is often not clear to healthcare providers how and where to document drug allergies. Besides the underreporting of drug allergies, outdated or inaccurate drug allergy information in EHRs poses an important problem. Research on the use of coding terminologies for documenting drug allergies is sparse. There is no generally accepted standard terminology for structured documentation of allergy information. The final key finding is the consistently reported low specificity of drug allergy alerts. Current systems have high alert override rates of up to 90%, leading to alert fatigue. Important challenges remain for increasing the specificity of drug allergy alerts. We found only one study specifically reporting outcomes related to CDSS for drug allergies. It showed that adverse drug events resulting from overridden drug allergy alerts do not occur frequently.

CONCLUSIONS

Accurate and comprehensive recording of drug allergies is required for good use of CDSS for drug allergy screening. We found considerable variation in the way drug allergy are recorded in EHRs. It remains difficult to reduce drug allergy alert overload while maintaining patient safety as the highest priority. Future research should focus on improving alert specificity, thereby reducing override rates and alert fatigue. Also, the effect on patient outcomes and cost-effectiveness should be evaluated.

Prescriber response to computerized drug alerts for electronic prescriptions among hospitalized patients

BACKGROUND

Clinical decision support systems (CDSS) reduce prescription errors, but their effectiveness is reduced by high alert rates, "alert fatigue", and indiscriminate rejection.

OBJECTIVES

To compare acceptance rates of alerts generated by the SafeRx^® prescription CDSS among different alert types and departments in a tertiary care hospital, identify factors associated with alert acceptance, and determine whether alert overrides were justified.

METHODS

In a retrospective study, we compared acceptance rates of all prescription alerts generated in 2013 in 18 departments of Israel's largest tertiary care center. In a prospective study in 2 internal medicine departments, we collected data on factors potentially associated with alert override, and an expert panel evaluated the justification for each overridden alert. We used multivariate analyses to examine the association between patient and physician-related factors and alert acceptance.

RESULTS

In the retrospective study, of 390,841 prescriptions, 37.1% triggered at least one alert, 5.3% of which were accepted. Acceptance rates ranged from 7.9% for excessive dose alerts to 4.0% for duplicate drug and major drug-drug interactions alerts (p<0.001). In the prospective study, common reasons for alert overriding included "irrelevance to the specific condition" and "medication previously tolerated by the patient". Weekend shifts (incident rate ratio [IRR]=1.50 [95% CI, 1.01-2.22]) and a specific department (IRR=1.87 [1.23-2.87]) were associated with higher alert acceptance, while night shift (IRR=0.47 [0.26-0.85]) was associated with alert override. Most alert overrides (88.6%) were judged justified.

CONCLUSIONS

The vast majority of SafeRx^® alerts are overridden, and overriding is justified in most cases. Minimizing the number of alerts is essential to reduce the likelihood of developing "alert fatigue". Our findings may inform a rational, department-specific approach for alert silencing.

Paracetamol overdosing in a tertiary care hospital: implementation and outcome analysis of a preventive alert programme

WHAT IS KNOWN AND OBJECTIVES

Paracetamol is a frequently used antipyretic and analgesic drug, but also a dose-dependent hepatotoxin. Unintentional paracetamol overdosing is a common medication error in hospitals. The present study aimed at (i) analysis of unintentional paracetamol overdosing in hospitalized patients; (ii) development, implementation and outcome analysis of an alert algorithm for the prevention of relevant paracetamol overdosing.

METHODS

All patients who received paracetamol in a Swiss tertiary care hospital during 2011 to 2014 were analysed to detect cases of paracetamol overdosing in a local pharmacoepidemiological database. In 2014, an automated algorithm screened the hospital's electronic prescribing system for patients at risk of overdosing, followed by expert validation. When imminent relevant overdosing was confirmed, alerts were issued to prescribers. Relevance was defined as prescriptions that permitted repeated daily paracetamol exposure of ≥5 g.

RESULTS AND DISCUSSION

From 2011 to 2013, relevant overdosing occurred in 11 patients (5-8 g/day for 3 to 5 days), which corresponds to 0·4 % of all patients exposed to any paracetamol overdosing (mean n = 988 per year). In 2014, alerts were issued by experts in 23 cases with subsequent changes to prescriptions in 21 (91·3 %) thereof. Although the occurrence of any paracetamol overdosing declined only marginally in 2014 (n = 914), no relevant overdosing occurred anymore.

WHAT IS NEW AND CONCLUSION

Unintentional paracetamol overdosing was frequent but only a small fraction thereof was deemed relevant. This proof of concept study analysed local hospital data and developed a preventive system combining sensitive automated detection with subsequent specific expert validation. The resulting alerts achieved high compliance and prevented relevant paracetamol overdosing.

Evaluation of an intravenous preparation information system for improving the reconstitution and dilution process

BACKGROUND

There are very few studies reporting the impact of providing intravenous (IV) preparation information on quality use of antimicrobials, particularly regarding their reconstitution and dilution. Therefore, to improve these processes in IV antimicrobial administration, an IV preparation information system (IPIS) was implemented in a hospital.

OBJECTIVE

We aimed to evaluate the effect of improving reconstitution and dilution by implementing an IPIS in the electronic medical record (EMR) system.

METHODS

Prescriptions and activity records of nurses for injectable antimicrobials that required reconstitution and dilution for IV preparation from January 2008 to December 2013 were retrieved from EMR, and assessed based on packaging label information for reconstituting and diluting solutions. We defined proper reconstitution and dilution as occurring when the reconstitution and dilution solutions prescribed were consistent with the nurses' acting records. The types of intervention in the IPIS were as follows: a pop-up alert for proper reconstitution and passive guidance for proper dilution. We calculated the monthly proper reconstitution rate (PRR) and proper dilution rate (PDR) and evaluated the changes in these rates and trends using interrupted time series analyses.

RESULTS

Prior to the initiation of the reconstitution alert and dilution information, the PRR and PDR were 12.7 and 46.1%, respectively. The reconstitution alert of the IPIS rapidly increased the PRR by 41% (p<0.001), after which the PRR decreased by 0.9% (p=0.013) per month after several months. However, there was no significant change in the rate or trend of the PDR during the study period.

CONCLUSIONS

This study demonstrated that the provision of reconstitution alerts by the IPIS contributed to improving the reconstitution process of IV antimicrobial injection administration. However, providing passive information on dilution solutions was ineffective. Furthermore, solutions to ensure the continuous effectiveness of alert systems are warranted and should be actively sought.

Clinically Inconsequential Alerts: The Characteristics of Opioid Drug Alerts and Their Utility in Preventing Adverse Drug Events in the Emergency Department

STUDY OBJECTIVE

We examine the characteristics of clinical decision support alerts triggered when opioids are prescribed, including alert type, override rates, adverse drug events associated with opioids, and preventable adverse drug events.

METHODS

This was a retrospective chart review study assessing adverse drug event occurrences for emergency department (ED) visits in a large urban academic medical center using a commercial electronic health record system with clinical decision support. Participants include those aged 18 to 89 years who arrived to the ED every fifth day between September 2012 and January 2013. The main outcome was characteristics of opioid drug alerts, including alert type, override rates, opioid-related adverse drug events, and adverse drug event preventability by clinical decision support.

RESULTS

Opioid drug alerts were more likely to be overridden than nonopioid alerts (relative risk 1.35; 95% confidence interval [CI] 1.21 to 1.50). Opioid drug-allergy alerts were twice as likely to be overridden (relative risk 2.24; 95% CI 1.74 to 2.89). Opioid duplicate therapy alerts were 1.57 times as likely to be overridden (95% CI 1.30 to 1.89). Fourteen of 4,581 patients experienced an adverse drug event (0.31%; 95% CI 0.15% to 0.47%), and 8 were due to opioids (57.1%). None of the adverse drug events were preventable by clinical decision support. However, 46 alerts were accepted for 38 patients that averted a potential adverse drug event. Overall, 98.9% of opioid alerts did not result in an actual or averted adverse drug event, and 96.3% of opioid alerts were overridden.

CONCLUSION

Overridden opioid alerts did not result in adverse drug events. Clinical decision support successfully prevented adverse drug events at the expense of generating a large volume of inconsequential alerts. To prevent 1 adverse drug event, providers dealt with more than 123 unnecessary alerts. It is essential to refine clinical decision support alerting systems to eliminate inconsequential alerts to prevent alert fatigue and maintain patient safety.