A clinical case of electronic health record drug alert fatigue: Consequences for patient outcome

Pediatrics

Volumn 131, Issue 6, 2013, Pages

  Carspecken, C William ^a,b   Sharek, Paul J ^c,d   Longhurst, Christopher ^d   Pageler, Natalie M ^d  

^a STANFORD UNIVERSITY   (United States)

^b HARVARD MEDICAL SCHOOL   (United States)

^c LUCILE PACKARD CHILDREN S HOSPITAL   (United States)

^d STANFORD UNIVERSITY SCHOOL OF MEDICINE   (United States)

Author keywords

Adverse drug event; Alert fatigue; Clinical decision support systems; Drug allergy; Electronic health record; Override; Pediatrics; Quality improvement

Indexed keywords

CHLOROTHIAZIDE; FUROSEMIDE; IMMUNOSUPPRESSIVE AGENT; SULFONAMIDE;

ARTICLE; CASE REPORT; CHILD; CHOLESTASIS; DEATH; DRUG CROSS REACTIVITY; DRUG ERUPTION; DRUG HYPERSENSITIVITY; DRUG TOLERABILITY; ELECTRONIC MEDICAL RECORD; GASTROSCHISIS; GRAFT VERSUS HOST REACTION; HOSPITAL ADMISSION; HUMAN; IMMUNOSUPPRESSIVE TREATMENT; INTENSIVE CARE UNIT; INTESTINE TRANSPLANTATION; LIVER TRANSPLANTATION; LUNG MYCOSIS; MALE; PATIENT SAFETY; PEDIATRICS; PRESCHOOL CHILD; PRIORITY JOURNAL; RESPIRATORY DISTRESS; RESPIRATORY FAILURE; SEPTIC SHOCK; SHORT BOWEL SYNDROME; TOTAL PARENTERAL NUTRITION;

EID: 84878716417     PISSN: 00314005     EISSN: 10984275     Source Type: Journal    
DOI: 10.1542/peds.2012-3252     Document Type: Article

References (22)

1. Bates DW, Gawande AA. Improving safety with information technology. N Engl J Med. 2003;348(25):2526-2534 (Pubitemid 36706541)
2. Garg AX, Adhikari NKJ, McDonald H, et al. Effects of computerized clinical decision support systems on practitioner performance and patient outcomes: a systematic review. JAMA. 2005;293(10):1223-1238 (Pubitemid 40327908)
3. Vaziri A, Connor E, Shepherd I, Jones RT, Chan T, de Lusignan S. Are we setting about improving the safety of computerised prescribing in the right way? A workshop report. Inform Prim Care. 2009;17(3):175-182
4. Caubet JC, Eigenmann PA. Diagnostic issues in pediatric drug allergy. Curr Opin Allergy Clin Immunol. 2012;12(4): 341-347
5. Schedlbauer A, Prasad V, Mulvaney C, et al. What evidence supports the use of computerized alerts and prompts to improve clinicians' prescribing behavior? J Am Med Inform Assoc. 2009;16(4):531-538
6. Lin CP, Payne TH, Nichol WP, Hoey PJ, Anderson CL, Gennari JH. Evaluating clinical decision support systems: monitoring CPOE order check override rates in the Department of Veterans Affairs' Computerized Patient Record System. J Am Med Inform Assoc. 2008;15(5):620-626
7. Hsieh TC, Kuperman GJ, Jaggi T, et al. Characteristics and consequences of drug allergy alert overrides in a computerized physician order entry system. J Am Med Inform Assoc. 2004;11(6):482-491 (Pubitemid 39421732)
8. Weingart SN, Toth M, Sands DZ, Aronson MD, Davis RB, Phillips RS. Physicians' decisions to override computerized drug alerts in primary care. Arch Intern Med. 2003;163 (21):2625-2631 (Pubitemid 37464421)
9. Stultz JS, Nahata MC. Computerized clinical decision support for medication prescribing and utilization in pediatrics. J Am Med Inform Assoc. 2012;19(6):942-953
10. Embi PJ, Leonard AC. Evaluating alert fatigue over time to EHR-based clinical trial alerts: findings from a randomized controlled study. J Am Med Inform Assoc. 2012; 19(e1):e145-e148
11. Horsky J, Schiff GD, Johnston D, Mercincavage L, Bell D, Middleton B. Interface design principles for usable decision support: a targeted review of best practices for clinical prescribing interventions. J Biomed Inform. 2012;45(6):1202-1216
12. Strom BL, Schinnar R, Apter AJ, et al. Absence of cross-reactivity between sulfonamide antibiotics and sulfonamide nonantibiotics. N Engl J Med. 2003;349(17):1628-1635 (Pubitemid 37288569)
13. Gaskin GL, Longhurst CA, Slayton R, Das AK. Sociotechnical challenges of developing an interoperable personal health record: lessons learned. Appl Clin Inform. 2011;2(4): 406-419
14. Hogan WR. Towards an ontological theory of substance intolerance and hypersensitivity. J Biomed Inform. 2011;44(1):26-34
15. Tatonetti NP, Ye PP, Daneshjou R, Altman RB. Data-driven prediction of drug effects and interactions. Sci Transl Med. 2012;4(125): 125ra31
16. van der Sijs H, Aarts J, van Gelder T, Berg M, Vulto A. Turning off frequently overridden drug alerts: limited opportunities for doing it safely. J Am Med Inform Assoc. 2008;15(4): 439-448 (Pubitemid 351885159)
17. Shah NR, Seger AC, Seger DL, et al. Improving acceptance of computerized prescribing alerts in ambulatory care. J Am Med Inform Assoc. 2006;13(1):5-11 (Pubitemid 41828329)
18. Kilbridge PM, Welebob EM, Classen DC. Development of the Leapfrog methodology for evaluating hospital implemented inpatient computerized physician order entry systems. Qual Saf Health Care. 2006;15(2): 81-84
19. Greenberg M, Ridgely MS. Clinical decision support and malpractice risk. JAMA. 2011; 306(1):90-91
20. Kesselheim AS, Cresswell K, Phansalkar S, Bates DW, Sheikh A. Clinical decision support systems could be modified to reduce 'alert fatigue' while still minimizing the risk of litigation. Health Aff (Millwood). 2011;30 (12):2310-2317
21. Longhurst CA, Landa HM. Health information technology and patient safety. BMJ. 2012;344:e1096
22. Jones SS, Heaton PS, Rudin RS, Schneider EC. Unraveling the IT productivity paradox-lessons for health care. N Engl J Med. 2012; 366(24):2243-2245