Heleen Van Der Sus, MSc, RPh, Jos Aarts, PhD, Arnold Volto, MSc, PPh, PhD, Marc Berg, MD, MA, PhD Overriding of Drug Safety Alerts in Computerized Physician Order Entry. J Am Med Inform Assoc. 2006 Mar-Apr;13(2):138-147

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An article published in the Journal of the American Medical Informatics Association by Van Der Sus, Heleen., et al. focused on reviewing literature on overriding drug safety alerts in computerized physician order entry (CPO). The authors utilized the Reason’s framework of accident causation to interpret their results. Seventeen papers met the author’s qualifications for inclusion in the review. This study sought to identify the issues facing clinical decision-making in correlation with computer aided alerting systems.

This publication was produced as a review of articles written on overriding clinical decision support system alerts and reminders. Many computerized physician order entry systems are designed to incorporate decision support systems that serve as a reminder to physicians entering patient orders of potential patient safety issues. Since clinical decision support has become and integral part of electronic ordering there has been studies done of its impact on patient care and clinical best practices. The authors sought to collectively review the articles published on decision support systems “to provide insight into physicians’ handling of safety alerts.” The reviewers asked a serious of questions one being: “How often and in what situations are safety alerts overridden?” The reviews concluded that except for serious alerts for overdose that alerts were overridden 49% to 96%. The article also mentioned that a study revealed that the override rate increased from 50% to 75% over a five-year period. The second question asked by the reviewers was “Why do physicians override them?” The authors concluded that more often than not physicians were suffering from “alert fatigue” which is what happens when they are exposed to a burdensome Decision Support System (DSS). They also stated that this fatigue causes physicians to ignore alerts that could be important to patient care. Yet another questions asked by the reviews was “What effects ensue?” The results were as follows: “Adverse events were observed in 2.3%, 2.5% and 6% of the overridden alerts, respectively, in studies with override rates of 57%, 90%, and 80%.” “Adverse events were preventable in 0.8% and none of the overrides, respectively.

The authors concluded by recommending that “entry of override decisions to gain a deeper insight into (justifying) override.” “Specificity or sensitivity should be increased as the result of consensus meetings between physicians and pharmacists.” Finally, “Decision support in CPOE can be a good tool to improve patient safety but can also hamper patient safety if it is poorly designed.”

Comments: Clinical decision support have been both praised and cursed by clinical users as helpful and hindering to patient care. We must continue to develop clinical decision support systems, however it is our duty as informatics professionals to design these systems in collaboration with users and reviewing lessoned learned and best practices from those who have gone before. I agree with the authors that DSS in CPOE can and is a good tool to improve patient safety, and yet we must also be aware that it can hinder patient care if we do not design it properly.