Optimization of clinical decision support through minimization of excessive drug allergy alerts

Brodowy, Bret; Nguyen, Dinh C.

doi:10.2146/ajhp150252

Cited by 16 publications

(6 citation statements)

References 8 publications

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“…As a result, a higher percentage of drug allergy alerts were being accepted by clinicians from (82% to 77%). The new alert rate identified observed in anotherthis study is like other similar studies published in a systemic review by Poly et al [24] Additionally, similar results were also observed by Brodowy et al, which reported an improvement of allergy alerts override rate from 94% to 90% after removal of non-clinically significant allergy alerts [26].…”

Section: Discussionsupporting

confidence: 88%

Impact of Redesign of a Clinical Decision Allergy and Drug Interactions Alerts in an Electronic Prescribing System on Patient Safety – A Quantitative Descriptive Study

Khalil

Hua

2021

International Journal of Digital Health

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Background: Electronic medication management systems (EMS) generate medication alerts such as Drug-Drug interaction (DDI) and allergy at the drug order entry point for clinicians to improve patients’ safety. EMS that provide non-clinically significant alerts contribute to alert fatigue and pose a risk for patients’ harm. The primary aim is to assess the impact of redesign of allergy and DDI alerts on alerts’ trigger and overrides rates. The secondary aim is to assess the impact of the redesign of the alerts on reported patients’ harm. Methodology: A retrospective cross sectional 2 stage study was conducted. Stage 1 involved analysis of inpatients’ electronic drug orders in the hospital’s EMS that triggered an allergy, or a DDI alert from October to December 2019 in a 650 bed Australian hospital. A report on the 50 commonly overridden allergy and DDI alerts was reviewed by a multidisciplinary team to assess the clinical significance of the alerts using a risk matrix tool, frequency of overrides as well as published literature on adverse effects. Subsequently, non-clinically significant allergies and DDI alerts were deactivated in EMS system in March 2020. Stage 2 of the study involved the same analysis conducted in stage 1 (March to May 2021). The number of alerts overrides, alert trigger rates and number of related reported incidents involving patients’ harm were analysed. Results: A total of 288,267 and 288,133 prescriptions orders were reviewed in the 2 stages respectively. A total of 12 DDI and 37 allergy alerts were deactivated in stage 2. Redesign of the alerts reduced the trigger rate of allergy alerts (4.96% to 3.77%, P < 0.0001) and DDI alerts (5.30% to 4.73%, P < 0.0001). A statistically significant reduction in the number of incidents with reported patients’ harm related to overrides of alerts was observed in the post intervention phase. The allergy alert trigger rate was reduced from 4.96% to 3.77%, P = 0.0172. Conclusion: The study demonstrated that using an evidence-based approach and a risk assessment matrix to deactivate non-clinically significant alerts potentially contribute to a decrease in patients’ harm. Highlights

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Section: Discussionsupporting

confidence: 88%

Impact of Redesign of a Clinical Decision Allergy and Drug Interactions Alerts in an Electronic Prescribing System on Patient Safety – A Quantitative Descriptive Study

Khalil

Hua

2021

International Journal of Digital Health

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“…After the removal of 110 duplicates and the exclusion of 276 articles following title and abstract screening, a total of 153 full texts were read. In compliance with the inclusion and exclusion criteria, 31 articles reporting quantitative and qualitative parameters 13 33 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60 61 62 63 64 65 66 67 and 29 articles reporting exclusively qualitative parameters of alert acceptance 1 6 12 17 32 68 69 70 71 72 73 74 75 76 77 78 79 80 81 82 83 84 85 86 87 88 89 90 91 were included in the analysis.…”

Section: Resultsmentioning

confidence: 99%

Modulators Influencing Medication Alert Acceptance: An Explorative Review

2022

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Objectives Clinical decision support systems (CDSSs) use alerts to enhance medication safety and reduce medication error rates. A major challenge of medication alerts is their low acceptance rate, limiting their potential benefit. A structured overview about modulators influencing alert acceptance is lacking. Therefore, we aimed to review and compile qualitative and quantitative modulators of alert acceptance and organize them in a comprehensive model. Methods In accordance with the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guideline, a literature search in PubMed was started in February 2018 and continued until October 2021. From all included articles, qualitative and quantitative parameters and their impact on alert acceptance were extracted. Related parameters were then grouped into factors, allocated to superordinate determinants, and subsequently further allocated into five categories that were already known to influence alert acceptance. Results Out of 539 articles, 60 were included. A total of 391 single parameters were extracted (e.g., patients' comorbidity) and grouped into 75 factors (e.g., comorbidity), and 25 determinants (e.g., complexity) were consequently assigned to the predefined five categories, i.e., CDSS, care provider, patient, setting, and involved drug. More than half of all factors were qualitatively assessed (n = 21) or quantitatively inconclusive (n = 19). Furthermore, 33 quantitative factors clearly influenced alert acceptance (positive correlation: e.g., alert type, patients' comorbidity; negative correlation: e.g., number of alerts per care provider, moment of alert display in the workflow). Two factors (alert frequency, laboratory value) showed contradictory effects, meaning that acceptance was significantly influenced both positively and negatively by these factors, depending on the study. Interventional studies have been performed for only 12 factors while all other factors were evaluated descriptively. Conclusion This review compiles modulators of alert acceptance distinguished by being studied quantitatively or qualitatively and indicates their effect magnitude whenever possible. Additionally, it describes how further research should be designed to comprehensively quantify the effect of alert modulators.

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“…Horsky et al [ 65 ] stated that the specificity and contextual relevance of alerts can be increased by periodically reviewing trigger rules, a thorough analysis of performance logs, and maintenance of accurate allergy, problem, and medication lists in EHRs. Additionally, Brodowy et al [ 58 ] demonstrated a reduction in DA alerts by simply eliminating alerts resulting from inactive ingredients.…”

Section: Resultsmentioning

confidence: 99%

Clinical Decision Support Systems for Drug Allergy Checking: Systematic Review

Légat¹,

Laere²,

Nyssen³

et al. 2018

J Med Internet Res

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BackgroundWorldwide, the burden of allergies—in particular, drug allergies—is growing. In the process of prescribing, dispensing, or administering a drug, a medication error may occur and can have adverse consequences; for example, a drug may be given to a patient with a documented allergy to that particular drug. Computerized physician order entry (CPOE) systems with built-in clinical decision support systems (CDSS) have the potential to prevent such medication errors and adverse events.ObjectiveThe aim of this review is to provide a comprehensive overview regarding all aspects of CDSS for drug allergy, including documenting, coding, rule bases, alerts and alert fatigue, and outcome evaluation.MethodsThe Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines were followed as much as possible and searches were conducted in 5 databases using CPOE, CDSS, alerts, and allergic or allergy as keywords. Bias could not be evaluated according to PRISMA guidelines due to the heterogeneity of study types included in the review.ResultsOf the 3160 articles considered, 60 met the inclusion criteria. A further 9 articles were added based on expert opinion, resulting in a total of 69 articles. An interrater agreement of 90.9% with a reliability Κ=.787 (95% CI 0.686-0.888) was reached. Large heterogeneity across study objectives, study designs, study populations, and reported results was found. Several key findings were identified. Evidence of the usefulness of clinical decision support for drug allergies has been documented. Nevertheless, there are some important problems associated with their use. Accurate and structured documenting of information on drug allergies in electronic health records (EHRs) is difficult, as it is often not clear to healthcare providers how and where to document drug allergies. Besides the underreporting of drug allergies, outdated or inaccurate drug allergy information in EHRs poses an important problem. Research on the use of coding terminologies for documenting drug allergies is sparse. There is no generally accepted standard terminology for structured documentation of allergy information. The final key finding is the consistently reported low specificity of drug allergy alerts. Current systems have high alert override rates of up to 90%, leading to alert fatigue. Important challenges remain for increasing the specificity of drug allergy alerts. We found only one study specifically reporting outcomes related to CDSS for drug allergies. It showed that adverse drug events resulting from overridden drug allergy alerts do not occur frequently.ConclusionsAccurate and comprehensive recording of drug allergies is required for good use of CDSS for drug allergy screening. We found considerable variation in the way drug allergy are recorded in EHRs. It remains difficult to reduce drug allergy alert overload while maintaining patient safety as the highest priority. Future research should focus on improving alert specificity, thereby reducing override rates and alert fatigue. Als...

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Optimization of clinical decision support through minimization of excessive drug allergy alerts

Cited by 16 publications

References 8 publications

Impact of Redesign of a Clinical Decision Allergy and Drug Interactions Alerts in an Electronic Prescribing System on Patient Safety – A Quantitative Descriptive Study

Impact of Redesign of a Clinical Decision Allergy and Drug Interactions Alerts in an Electronic Prescribing System on Patient Safety – A Quantitative Descriptive Study

Modulators Influencing Medication Alert Acceptance: An Explorative Review

Clinical Decision Support Systems for Drug Allergy Checking: Systematic Review

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