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Drug Saf. 2019 Apr;42(4):573-579. doi: 10.1007/s40264-018-0756-x.

Evaluation of Harm Associated with High Dose-Range Clinical Decision Support Overrides in the Intensive Care Unit.

Wong A1,2,3, Rehr C2,3,4, Seger DL2,3,4, Amato MG1,2,3, Beeler PE2,3,5,6, Slight SP2,3,7,8, Wright A3,6, Bates DW9,10,11.

Author information

1
Department of Pharmacy Practice, MCPHS University, Boston, MA, USA.
2
The Center for Patient Safety Research and Practice, Brigham and Women's Hospital, Boston, MA, USA.
3
Division of General Internal Medicine and Primary Care, Brigham and Women's Hospital, Boston, MA, USA.
4
Clinical and Quality Analysis, Partners HealthCare, Somerville, MA, USA.
5
Research Center for Medical Informatics, University Hospital, Zurich, Switzerland.
6
Harvard Medical School, Boston, MA, USA.
7
School of Pharmacy, Newcastle University, King George VI Building, Queen Victoria Road, Newcastle upon Tyne, UK.
8
Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle upon Tyne, UK.
9
The Center for Patient Safety Research and Practice, Brigham and Women's Hospital, Boston, MA, USA. dbates@partners.org.
10
Division of General Internal Medicine and Primary Care, Brigham and Women's Hospital, Boston, MA, USA. dbates@partners.org.
11
Harvard Medical School, Boston, MA, USA. dbates@partners.org.

Abstract

INTRODUCTION:

Medication-related clinical decision support (CDS) alerts have been shown to be effective at reducing adverse drug events (ADEs). However, these alerts are frequently overridden, with limited data linking these overrides to harm. Dose-range checking alerts are a type of CDS alert that could have a significant impact on morbidity and mortality, especially in the intensive care unit (ICU) setting.

METHODS:

We performed a single-center, prospective, observational study of adult ICUs from September 2016 to April 2017. Targeted overridden alerts were triggered when doses greater than or equal to 5% over the maximum dose were prescribed. The primary outcome was the appropriateness of the override, determined by two independent reviewers, using pre-specified criteria formulated by a multidisciplinary group. Overrides which resulted in medication administration were then evaluated for ADEs by chart review.

RESULTS:

The override rate of high dose-range alerts in the ICU was 93.0% (total n = 1525) during the study period. A total of 1418 overridden alerts from 755 unique patients were evaluated for appropriateness (appropriateness rate 88.8%). The most common medication associated with high dose-range alerts was insulin regular infusion (n = 262, 18.5%). The rates of ADEs for the appropriately and inappropriately overridden alerts per 100 overridden alerts were 1.3 and 5.0, respectively (p < 0.001).

CONCLUSIONS:

Overriding high dose-range CDS alerts was found to be common and often appropriate, suggesting that more intelligent dose checking is needed. Some alerts were clearly inappropriately presented to the provider. Inappropriate overrides were associated with an increased risk of ADEs, compared to appropriately overridden alerts.

PMID:
30506472
DOI:
10.1007/s40264-018-0756-x
[Indexed for MEDLINE]

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