Overriding alerts that are clinically relevant can potentially lead to harm.
Two things are likely familiar to any physician working in an electronic medical record: Seeing clinical decision support (CDS) alerts and overriding those alerts.
Such alerts remind clinicians about everything from a patient's drug allergies, to possible drug interactions, to dosing guidelines, to lab testing guidance. Clinicians can either follow the alerts' recommendations or override or ignore them.
"They're frequently overridden, and often these are done appropriately," says Adrian Wong, PharmD, MPH, BCPS, BCCCP, an outcomes research and pharmacy informatics fellow in the division of general internal medicine and primary care at Brigham and Women's Hospital.
However, overriding alerts that are clinically relevant can potentially lead to harm.
That's the conclusion of a new study in BMJ Quality & Safety, "Prospective evaluation of medication-related clinical decision support over-rides in the intensive care unit."
The prospective observational study examined medication-related CDS over-rides among adults admitted to any of six Brigham and Women's ICUs between July 2016 and April 2017.
The study included 2,448 over-ridden alerts from 712 unique patient encounters. Although 81.6% of the overrides were appropriate, the "inappropriate over-rides were six times as likely to be associated with potential and definite ADEs [adverse drug events], compared with appropriate over-rides."
For example, in two cases in the study, physicians ordered certain medications even though there was a "reaction that was documented" and "there were other alternative options available," says Wong, the study's lead author. In both cases, the patients had a similar adverse drug event to what was documented.
However, the doctors "might not even have realized that they had encountered this alert at all because of the amount that they encounter," he says.
Wong says that ICU patients have a higher risk of ADEs because they're generally sicker, in the hospital longer, and receive more medications than other hospital patients.
Wong's past research over a three-year period at a 793-bed tertiary-care teaching institution has shown that almost three-quarters of alerts were overridden and 40% of the overrides were not appropriate, and that appropriateness of medication-related CDS overrides in the ICU varied by the type of alert.
However, researchers "haven't really evaluated why [we] should care that they're overridden" until now, Wong says.
Although other research has shown that clinicians find alerts to be "excessive," such a huge increase in the risk for ADEs indicate that some clinical alerts convey critical information. For example, one study found that the "use of CPOE [computerized physician order entry] and isolated CDSSs [clinical decision support systems] can substantially reduce medication error rates."
That research conducted systematic reviews of studies that evaluated the effect of CPOE and CDSSs systems on medication safety, and found that:
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.
That leads to the possibility that too many—and not the right kind—of alerts are to blame. Even though Wong's team didn't delve into the "why" of CDS overrides, he says it is likely due to alert fatigue.
In addition, "this alert fatigue may lead to providers not trusting the system because of all the clinically irrelevant alerts they find" (and potentially alerts that they had expected to see but did not encounter)," he added later via email.
"More alerts are happening and added to the system without looking at the clinical relevance," he says.
What's the solution?
When asked whether the answer to the problem lies in a technology solution or clinician solution, Wong replied that "it's everyone's solution," meaning that IT teams, vendors, and providers need to work together to gain buy-in, be able to tailor alerts to institutional needs, and critically evaluate what alerts are necessary.
For example, at his own institution, Wong says the team is currently in process of making suggestions for improvements, such as eliminating alerts for medication orders of electrolytes, a change that would reduce the number of renal alerts significantly.
In addition, simply reducing the number of alerts isn't always the answer.
"There are studies that evaluate just reducing number of alerts in an institution with varying success," Wong says.
"You should evaluate these alerts and see what you can do to improve or reduce the alerts that shouldn't be there or that are clinically irrelevant," Wong says.
He advises that healthcare organizations work with clinicians and CDS teams to evaluate which alerts are firing and whether they're right for that institution's unique needs.
"These clinicians are often not incorporated from the beginning from these decisions," Wong says. "Really paying attention to the frontline clinicians is really important to identifying areas of improvement."
Alexandra Wilson Pecci is an editor for HealthLeaders.
