Reasons provided by prescribers when overriding drug-drug interaction alerts
Any J grizzle, pharmD, maysaaH. Mahmood, MS; Yu Ko, MS; John E. Murphy, PharmD. Reasons provided by prescribers when overriding drug-drug interaction alerts; The American Journal of managed care. Vol 13, NO.10.
Preventable adverse drug events comprise a large percentage of reported medical errors. An adverse drug event is defined as “an injury resulting from a medical intervention related to a Drug-drug interaction (DDIs). The risk of DDIs to patient safety is substantial, and the economic burden on the healthcare system that occurs when interaction leads to patient morbidity is significant.
The prescription medication process could be divided into three phases: the prescription, dispensing and administering and finally monitoring the patient. Communication between the individuals carrying those steps in the prescription process is very important for patient safety. Studies have shown that physicians and other prescribers fail to recognize between 37% and 47% of clinically meaningful DDIs. A solution for reducing the incidence of DDIs at the prescribing phase is the use of computerized physician order entry (CPOE) system that allows prescribers to enter orders electronically. These systems can provide an immediate alert to a prescriber who is trying to order a medication that interacts with another medication the patient is already receiving. However, it has been shown that physicians frequently override such alerts, with some CPOE systems requiring physicians to enter a reason for this decision.
This study was conducted to evaluate the DDIs override reasons provided by prescribers using a CPOE system at 6 Veterans affairs medical centers (VAMCs). The objective of the study was to determine the frequency at which physicians override DDI alerts, and to categorize the override reasons and to determine whether the reasons were useful to the pharmacists dispensing the medications.
Data related to prescriber’s reasons for overriding DDI alerts used in the VAMC system were obtained from ambulatory pharmacy dispensing records at 6 VAMC sites. The override reasons were collected over a period of one year from July 1, 2003 to June 30, 2004. The VA classifies 2 levels of severity for DDIs, critical and significant interactions. When a DDI alert message appears, the prescriber could either cancel the order, or override the alert and complete the prescription. It was mandatory for the prescribers to give reasons for critical interaction alerts only. The reasons were entered as free text. Once the provider verifies that an order is desired, the order with override reasons if applicable are sent to the pharmacy to be reviewed and approved.
The reasons collected were organized into 14 major categories developed by the authors. Each reason was then evaluated and rated as being clinically useful or not to the pharmacist for his/her assessment before dispensing the medication.
A total of 15,848 unique DDI overrides occurred during the first year of study. The DDI override reasons were reviewed, assessed and categorized. It was found that 72% of the DDIs were critical interactions. An override reason was not provided for 53% of these critical DDIs. When override reasons were documented, approximately 43% of those critical DDIs were rated as useful and 50% for significant DDIs were rated as useful. For significant DDIs, 4% included an override reason, with 50% of those being rated as useful. The 3 most common categories were identified for each of the study sites. There was consistency in that 4 of 6 sites had the same 3 categories (“no reason provided”, “patient has been taking combination”, and “patient being monitored”) in the same order. The other 2 sites shared the same top 3 categories (“no reason provided”, “prescriber aware of interaction” and “patient being monitored”).
The reasons for overrides by prescribers at VAMCs in this study were difficult to assess because reasons were not provided 84% of the time. The reason for this might be that the prescribers felt that providing response is an increased burden that could be safely ignored. In addition, prescribers may not view the alert system as a means of communication with the pharmacist but rather as a tool to help in their decision making. Although the response was mandatory for critical DDI overrides in the VAMC system, 53% of these fields were left blank. A possible explanation for a blank field is that the system interprets the space bar or the enter key as a response and essentially allows no response from the prescriber.
It is clear from this study that additional attention is needed to provide solutions that will improve the prescriber’s ability to communicate with the pharmacist and to ensure optimal patient outcomes with every medication prescribed.
Using free text fields to enter reasons for overrides in the CPOE system might be the reason behind the lack of communication between the prescriber and the pharmacist. Incorporating preformatted responses and drop-down menus to express clinician’s rationales may enhance communication. More studies are needed to examine the response of the pharmacists to specific override reasons and the clinical outcomes associated with the potential DDI reaching patients.
Submitted by (Bassima Hammoud)
A. J. Grizzle, M. H. Mahmood, Yu Ko, J. E. Murphy, E. P. Armstrong, G. H. Skrepnek, W. N. Jones, G. P. Schepers W. Paul Nichol, A. Houranieh, D. C. Dare, C. T. Hoey, and D. C. Malone. Reasons Provided by Prescribers When Overriding Drug-Drug Interaction Alerts. Am J Manag Care. 2007;13:573-580
Reasons Provided by Prescribers When Overriding Drug-Drug Interaction Alerts.
Adverse drug events are known to be the most common cause of medical errors. A large percentage of these adverse drug events are preventable. An adverse drug event is defined as “an injury resulting from a medical intervention related to a drug. Drug–drug interactions (DDIs) are common causes of preventable adverse drug events, with 20% to 30% of adverse drug events attributed to interactions between drugs. During the prescription medication use process, at all stages it is possible to prevent harmful DDIs or other adverse drug events. The use of computerized prescriber order entry (CPOE) systems with drug interaction alerts is a potential solution for reducing the incidence of DDIs at the prescribing phase. However, it has been shown that physicians frequently override such alerts. Some CPOE systems require prescribers to enter a reason for overriding an alert of clinical relevance. This can serve as a quality control aspect, while also providing information for those dispensing or administering the medication or for those monitoring the patient. The objectives of this study were to determine the frequency at which physicians override DDI alerts, to categorize the override reasons, and to determine whether the override reasons communicated useful information to pharmacists dispensing the prescribed medication.
Data from 6 VAMC Systems were collected over a period of 1 year. Prescribers’ reasons for overriding DDI alerts used in the VAMC system were obtained from ambulatory pharmacy dispensing records. The VA system classifies 2 levels of severity for DDIs, namely “critical” and “significant” interactions. Only critical interactions require an override reason. The override reason is entered in free text; there were no preset responses available such as drop-down menus. Once a provider verifies that an order is desired, the order and corresponding override reason are sent to the pharmacy to be reviewed and approved. If the pharmacist rater perceived that the physician had clearly documented awareness of the potential interaction and had indicated that measures had been taken to mitigate harm, the override reason was rated as useful. Given that medical records were not used in this study, the rating was based solely on the reason provided by the prescriber. The statistics for the first round and for the overall agreement for clinical usefulness were 0.42 and 0.86, respectively (P < .001). Seventy -two percent of DDIs were critical interactions. Twenty percent of the critical DDI override reasons (including no responses) were rated as useful. The most common response was “no response” (53%). When override reasons were documented, approximately 43% of those for critical interactions were rated as useful, and 50% of those for significant DDIs when provided, were rated as useful. Some of the other responses were “the interactions were not clinically significant (21.6%), the patient currently tolerated (21.6%), the patient was no longer taking 1 of the offending agents (8.0%) or had previously tolerated the combination (12.3%), and a short-term course of therapy was planned for 1 of the agents (6.2%). Furthermore, 40.6% of alerts were considered invalid (ie, not appropriate for the situation).” Some of the reasons prescribers may not have felt the need to provide override reasons were their assumption that other caretakers have access to patient medical records or that most of the alerts were not significant and that providing a response was an increased burden associated with the prescribing process that could be safely ignored. In addition, prescribers may not view the alert system as a means of communication to the pharmacist. The authors concluded with the following suggestions:
- A feedback mechanism should be incorporated into the DDI alert process as an educational process.
- Patient relevant medication history should be incorporated into the DDI alerts.
- Once an acceptable override reason is provided for a particular patient, repeat alert messages on refills should be eliminated.
- Drop-down menus could be used to more clearly and efficiently communicate override reasons. # Override reason responses for both significant and critical interactions should be mandatory.
- Alternative management strategies should be available to prescribers when DDI alerts are first issued. This would provide opportunities for timely decisions to make changes in medication selection.
Though most of the time the override appears clinically justifiable, the lack of response places additional burden on other healthcare professionals and especially on pharmacists. Proper communication can serve as a back-up safety net in the prescription medication use process. The frequency of overrides and reasons for overrides can be used as a quality measure of the alert system. Frequent irrelevant alerts can lead to ‘alert fatigue’ and result in physicians overlooking critical alerts. Designing appropriate messages are crucial to the success of the system. Messages should be evidence-based, should be perceived as useful and informative by practitioners and the system should have a minimal impact on the time required for the practitioner to complete an order. Considering the fact that ADEs are the most common cause of medical errors more research needs to be done for information systems to provide clinically useful information for all healthcare providers throughout the medication use process to improve patient safety. References
1. GPs’ views on computerized drug interaction alerts: questionnaire survey. D. Magnus, S. Rodgers and A. J. Avery. Journal of Clinical Pharmacy and Therapeutics (2002) 27, 377–382. 2. Prescribers' Responses to Alerts During Medication Ordering in the Long Term Care Setting. James Judge, Terry S. Field, Martin DeFlorio, Jane Laprino, Jill Auger, Paula Rochon, David W. Bates, and Jerry H. Gurwitz.J Am Med Inform Assoc. 2006 Jul–Aug; 13(4): 385–390. doi: 10.1197/jamia.M1945.
3. Saul N. Weingart, MD, PhD; Maria Toth, MD, PhD; Daniel Z. Sands, MD, MPH; Mark D. Aronson, MD; Roger B. Davis, ScD; Russell S. Phillips. Physicians' Decisions to Override Computerized Drug Alerts in Primary Care. Arch Intern Med. 2003;163:2625-2631.