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

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.

Determining Inappropriate Medication Alerts from "Inaccurate Warning" Overrides in the Intensive Care Unit.

OBJECTIVE: This article aims to understand provider behavior around the use of the override reason "Inaccurate warning," specifically whether it is an effective way of identifying unhelpful medication alerts. MATERIALS AND METHODS: We analyzed alert overrides that occurred in the intensive care units (ICUs) of a major academic medical center between June and November 2016, focused on the following high-significance alert types: dose, drug-allergy alerts, and drug-drug interactions (DDI). Override appropriateness was analyzed by two independent reviewers using predetermined criteria. RESULTS: A total of 268 of 26,501 ICU overrides (1.0%) used the reason "Inaccurate warning," with 93 of these overrides associated with our included alert types. Sixty-one of these overrides (66%) were identified to be appropriate. Twenty-one of 30 (70%) dose alert overrides were appropriate. Forty of 48 drug-allergy alert overrides (83%) were appropriate, for reasons ranging from prior tolerance (n = 30) to inaccurate ingredient matches (n = 5). None of the 15 DDI overrides were appropriate. CONCLUSION: The "Inaccurate warning" reason was selectively used by a small proportion of providers and overrides using this reason identified important opportunities to reduce excess alerts. Potential opportunities include improved evaluation of dosing mechanisms based on patient characteristics, inclusion of institutional dosing protocols to alert logic, and evaluation of a patient's prior tolerance to a medication that they have a documented allergy for. This resource is not yet routinely used for alert tailoring at our institution but may prove to be a valuable resource to evaluate available alerts.

Prospective evaluation of medication-related clinical decision support over-rides in the intensive care unit.

BACKGROUND: Clinical decision support (CDS) displayed in electronic health records has been found to reduce the incidence of medication errors and adverse drug events (ADE). Recent data suggested that medication-related CDS alerts were frequently over-ridden, often inappropriately. Patients in the intensive care unit (ICU) are at an increased risk of ADEs; however, limited data exist on the benefits of CDS in the ICU. This study aims to evaluate potential harm associated with medication-related CDS over-rides in the ICU. METHODS: This was a prospective observational study of adults admitted to any of six ICUs between July 2016 and April 2017 at our institution. Patients with provider-overridden CDS for dose (orders for scheduled frequency and not pro re nata), drug allergy, drug-drug interaction, geriatric and renal alerts (contraindicated medications for renal function or renal dosing) were included. The primary outcome was the appropriateness of over-rides, which were evaluated by two independent reviewers. Secondary outcomes included incidence of ADEs following alert over-ride and risk of ADEs based on over-ride appropriateness. RESULTS: A total of 2448 over-ridden alerts from 712 unique patient encounters met inclusion criteria. The overall appropriateness rate for over-rides was 81.6% and varied by alert type. More ADEs (potential and definite) were identified following inappropriate over-rides compared with appropriate over-rides (16.5 vs 2.74 per 100 over-ridden alerts, Fisher's exact test P<0.001). An adjusted logistic regression model showed that inappropriate over-rides were associated with an increased risk of ADEs (OR 6.14, 95% CI 4.63 to 7.71, P<0.001). CONCLUSIONS: Approximately four of five identified CDS over-rides were appropriately over-ridden, with the rate varying by alert type. However, inappropriate over-rides were six times as likely to be associated with potential and definite ADEs, compared with appropriate over-rides. Further efforts should be targeted at improving the positive predictive value of CDS such as by suppressing alerts that are appropriately over-ridden.