Overrides of clinical decision support alerts in primary care clinics

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Clinical decision support systems (CDS) can help prevent medication errors by providing physicians with real-time, relevant guidance at the various stages in the health care process. A key issue now is the amount of control physicians have over their responses to the alerts. Physicians continue to override CDS alerts despite system being modified to improve user acceptance. Alert overrides occur when clinicians do not follow the guidance presented by the alert, such overrides may be a barrier to improve patient and process outcomes. [1]


All CDS Level 2 alert overrides (which require a coded override reason) over a three-year 2009-2011 were analyzed. Our sample was limited to those providers working in primary care practices affiliated with two Harvard teaching hospitals, Massachusetts General Hospital and the Brigham and Women’s Hospital (Boston, MA). Our primary outcome was the rate of CDS alert overrides, and secondary outcome measure the coded reasons provided by physicians at the time of prescribing.


52.6% of CDS alerts were overridden during the three-year period. Those mostly overridden were formulary substitutions (85.0%), age-based substitution (79.0%), renal substitutions (78.0%), and drug allergy (77.4%). Physicians overrode (77.4%) of the drug-allergy alerts, with the most common reason given that patient had taken the drug previously without allergic reaction.


The override rate of drug-allergy alerts was found to be higher than that of drug-drug interaction alerts and duplicate therapy alerts across the three years. Many of these alerts warn of potential significant patient harm. This study looked at six different types of CDS alerts and showed how the override reasons varied widely depending on the type of alert.


Alert overrides occurs when clinicians do not follow the guidance presented by alert and hence can hinder improved patient outcomes and cause patient harm. This study gives us an idea to which area overrides are most likely to occur when entering a patient encounter summary. More studies and research needs to be done to understand the pattern and appropriateness of these override behaviors. .


  1. Slight2013 Overrides of clinical decision support alerts in primary care clinics http://www.ncbi.nlm.nih.gov/pubmed/23920697