Clinicians Override Most Medication Alerts

Laurie Barclay, MD

February 11, 2009

February 11, 2009 — Because clinicians override most current medication safety alerts generated by electronic prescribing systems, these warnings may be insufficient to protect patient safety, according to the results of a retrospective analysis in the February 9 issue of Archives of Internal Medicine.

"Electronic prescribing clearly will improve medication safety, but its full benefit will not be realized without the development and integration of high-quality decision support systems to help clinicians better manage medication safety alerts," senior author, Saul Weingart, MD, PhD, vice president for patient safety at Dana-Farber and an internist at Beth Israel Deaconess Medical Center (BIDMC) in Boston, Massachusetts, said in a news release. "We need to find a way to help clinicians to separate the proverbial wheat from the chaff. Until then, electronic prescribing systems stand to fall far short of their promise to enhance patient safety and to generate greater efficiencies and cost savings."

The investigators reviewed 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. Multivariate techniques helped to determine factors associated with alert acceptance.

Alerts were generated by 6.6% of electronic prescription attempts; most of these (61.6%) were high-severity interactions. Overall, clinicians accepted 23.0% of allergy alerts and 9.2% of drug interaction alerts. Clinicians accepted 10.4% of high-severity, 7.3% of moderate-severity, and 7.1% of low-severity interaction alerts (P < .001 for high-severity vs moderate- and low-severity interaction alerts).

Depending on the classes of interacting drugs, clinicians accepted 2.2% to 43.1% of high-severity interaction alerts. Clinicians of different specialties did not differ in alert acceptance, according to the results of multivariable analyses (P =.16). If the patient had previously received the medication for which an alert was posted, clinicians were less likely to accept the drug interaction alert (odds ratio, 0.03; 95% confidence interval, 0.03 – 0.03).

Limitations of this study included analysis of prescriptions written using only 1 electronic prescribing system; inference about an alert's utility based on the clinician's decision to accept or override an alert; assumption that a clinician's decision to override an alert was based on sound clinical judgment, without verification from the medical record; and inability to examine several patient and clinician characteristics, such as patient comorbidities and clinician familiarity, with the use of electronic medical records.

"The sheer volume of alerts generated by electronic prescribing systems stands to limit the safety benefits," said first author Thomas Isaac, MD, MBA, MPH, from BIDMC and Dana-Farber. "Too many alerts are generated for unlikely events, which could lead to alert fatigue. Better decision support programs will generate more pertinent alerts, making electronic prescribing more effective and safer."

The Physicians' Foundation for Health Systems Excellence supported this study. The study authors have disclosed no relevant financial relationships.

Arch Intern Med. 2009;169:305–311.


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