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.
Method:
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.
Results:
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”).
Discussion:
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.
Comments:
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)
