Are medication alerts useless since most clinicians override them anyway?

A February 2009 internal medicine study entitled “Overrides of Medication Alerts in Ambulatory Care” concludes the following:

Clinicians override most medication alerts, suggesting that current medication safety alerts may be inadequate to protect patient safety.

In my work I have certainly seen many alerts constantly being overridden but I didn’t realize how big an issue it was until I read this article. Here’s what else they said:

Background Electronic prescribing systems with decision support may improve patient safety in ambulatory care by offering drug allergy and drug interaction alerts. However, preliminary studies show that clinicians override most of these alerts.

Methods We performed a retrospective analysis of 233 537 medication safety alerts generated by 2872 clinicians in Massachusetts, New Jersey, and Pennsylvania who used a common electronic prescribing system from January 1, 2006, through September 30, 2006. We used multivariate techniques to examine factors associated with alert acceptance.

Results A total of 6.6% of electronic prescription attempts generated alerts. Clinicians accepted 9.2% of drug interaction alerts and 23.0% of allergy alerts. High-severity interactions accounted for most alerts (61.6%); clinicians accepted high-severity alerts slightly more often than moderate- or low-severity interaction alerts (10.4%, 7.3%, and 7.1%, respectively; P < .001). Clinicians accepted 2.2% to 43.1% of high-severity interaction alerts, depending on the classes of interacting medications. In multivariable analyses, we found no difference in alert acceptance among clinicians of different specialties (P = .16). Clinicians were less likely to accept a drug interaction alert if the patient had previously received the alerted medication (odds ratio, 0.03; 95% confidence interval, 0.03-0.03).

Conclusion Clinicians override most medication alerts, suggesting that current medication safety alerts may be inadequate to protect patient safety.

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3 thoughts on “Are medication alerts useless since most clinicians override them anyway?

  1. It proves the age old, the human “computer” is infinitely better than the dumb computers of our age.
    Rather than to try to overrule or second guess the clinician, decision support systems should attempt to support the clinical at tasks where the system can be better.

    It is also a good case point for adopting machine learning and actually try to improve the addressing of alerts over time. Data points out that just over 90% of the interaction alerts where disregarded, sounds more like a nuisance rather than work support…

  2. andy : Data points out that just over 90% of the interaction alerts where disregarded, sounds more like a nuisance rather than work support…
    andy did not rate this post.

    I don’t think so. The study doesn’t address how many of those 90% resulted in ADEs.

    The content may not be perfect; but those alerts didn’t get into the system by accident. Some type of evidence was used to create them.

    Maybe the systems should be designed so that if a clinician overrides and alert they also have to chose one or more of a few options as to why they did so. Giving feedback to the content suppliers to improve quality. Or possibly point out clinical mistakes?

  3. @ Tim Cook
    Yes some type of evidence was used to produce them, but without knowledge of the doctors intent in prescribing a drug, how can you with any success try to alert meaningful dangers?

    I am wholeheartedly in line with documenting any overrides. If the alerts are placed at meaningful patterns (rather than covering the hospitals backs) this could create useful input into revising the alerts and or treatment (however there are evidence hinting at patients actually suffer from doctors overriding well intentioned alerts, doctors doesn’t always know best).

    However this is all dependent on good quality alerts as well as easy and valid feedback (i.e. not ending up in a situation where all overrides are classified as “other reason” or similar).

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