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Computerized drug prescribing alerts can improve patient safety, but are often overridden because of poor specificity and alert overload. Our objective was to improve clinician acceptance of drug alerts by designing a selective set of drug alerts for the ambulatory care setting and minimizing workflow disruptions by designating only critical to high-severity alerts to be interruptive to clinician workflow. The alerts were presented to clinicians using computerized prescribing within an electronic medical record in 31 Boston-area practices. There were 18,115 drug alerts generated during our six-month study period. Of these, 12,933 (71%) were noninterruptive and 5,182 (29%) interruptive. Of the 5,182 interruptive alerts, 67% were accepted. Reasons for overrides varied for each drug alert category and provided potentially useful information for future alert improvement. These data suggest that it is possible to design computerized prescribing decision support with high rates of alert recommendation acceptance by clinicians. [ABSTRACT FROM AUTHOR]

Objective: The aim of this study was to evaluate the impact of an integrated patient-specific electronic clinical reminder system on diabetes and coronary artery disease (CAD) care and to assess physician attitudes toward this reminder system.Design: We enrolled 194 primary care physicians caring for 4549 patients with diabetes and 2199 patients with CAD at 20 ambulatory clinics. Clinics were randomized so that physicians received either evidence-based electronic reminders within their patients' electronic medical record or usual care. There were five reminders for diabetes care and four reminders for CAD care.Measurements: The primary outcome was receipt of recommended care for diabetes and CAD. We created a summary outcome to assess the odds of increased compliance with overall diabetes care (based on five measures) and overall CAD care (based on four measures). We surveyed physicians to assess attitudes toward the reminder system.Results: Baseline adherence rates to all quality measures were low. While electronic reminders increased the odds of recommended diabetes care (odds ratio [OR] 1.30, 95% confidence interval [CI] 1.01-1.67) and CAD (OR 1.25, 95% CI 1.01-1.55), the impact of individual reminders was variable. A total of three of nine reminders effectively increased rates of recommended care for diabetes or CAD. The majority of physicians (76%) thought that reminders improved quality of care.Conclusion: An integrated electronic reminder system resulted in variable improvement in care for diabetes and CAD. These improvements were often limited and quality gaps persist. [ABSTRACT FROM AUTHOR]

Background: Adverse event surveillance approaches underestimate the prevalence of harmful diagnostic errors (DEs) related to hospital care., Methods: We conducted a single-centre, retrospective cohort study of a stratified sample of patients hospitalised on general medicine using four criteria: transfer to intensive care unit (ICU), death within 90 days, complex clinical events, and none of the aforementioned high-risk criteria. Cases in higher-risk subgroups were over-sampled in predefined percentages. Each case was reviewed by two adjudicators trained to judge the likelihood of DE using the Safer Dx instrument; characterise harm, preventability and severity; and identify associated process failures using the Diagnostic Error Evaluation and Research Taxonomy modified for acute care. Cases with discrepancies or uncertainty about DE or impact were reviewed by an expert panel. We used descriptive statistics to report population estimates of harmful, preventable and severely harmful DEs by demographic variables based on the weighted sample, and characteristics of harmful DEs. Multivariable models were used to adjust association of process failures with harmful DEs., Results: Of 9147 eligible cases, 675 were randomly sampled within each subgroup: 100% of ICU transfers, 38.5% of deaths within 90 days, 7% of cases with complex clinical events and 2.4% of cases without high-risk criteria. Based on the weighted sample, the population estimates of harmful, preventable and severely harmful DEs were 7.2% (95% CI 4.66 to 9.80), 6.1% (95% CI 3.79 to 8.50) and 1.1% (95% CI 0.55 to 1.68), respectively. Harmful DEs were frequently characterised as delays (61.9%). Severely harmful DEs were frequent in high-risk cases (55.1%). In multivariable models, process failures in assessment, diagnostic testing, subspecialty consultation, patient experience, and history were significantly associated with harmful DEs., Conclusions: We estimate that a harmful DE occurred in 1 of every 14 patients hospitalised on general medicine, the majority of which were preventable. Our findings underscore the need for novel approaches for adverse DE surveillance., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2024. No commercial re-use. See rights and permissions. Published by BMJ.)

Importance: The transfer of patients between hospitals (interhospital transfer, IHT), exposes patients to communication errors and gaps in information exchange., Objective: To design and implement a standardised accept note to improve communication during medical service transfers, and evaluate its impact on patient outcomes., Design: Prospective interventional cohort study., Setting: A 792-bed tertiary care hospital., Participants: All patient transfers from any acute care hospital to the general medicine, cardiology, oncology and intensive care unit (ICU) services between August 2020 and June 2022., Interventions: A standardised accept note template was developed over a 9-month period with key stakeholder input and embedded in the electronic health record, completed by nurses within the hospital's Access Centre., Main Outcomes and Measures: Primary outcome was clinician-reported medical errors collected via surveys of admitting clinicians within 72 hours after IHT patient admission. Secondary outcomes included clinician-reported failures in communication; presence and 'timeliness' of accept note documentation; patient length of stay (LOS) after transfer; rapid response or ICU transfer within 24 hours and in-hospital mortality. All outcomes were analysed postintervention versus preintervention, adjusting for patient demographics, diagnosis, comorbidity, illness severity, admitting service, time of year, hospital COVID census and census of admitting service and admitting team on date of admission., Results: Of the 1004 and 654 IHT patients during preintervention and postintervention periods, surveys were collected on 735 (73.2%) and 462 (70.6%), respectively. Baseline characteristics were similar among patients in each time period and between survey responders and non-responders. Adjusted analyses demonstrated a 27% reduction in clinician-reported medical error rates postimplementation versus preimplementation (11.5 vs 15.8, adjusted OR (aOR) 0.73, 95% CI 0.53 to 0.99). Secondary outcomes demonstrated lower adjusted odds of clinician-reported failures in communication (aOR 0.88; 0.78 to 0.98) and rapid response/ICU transfer (aOR 0.57; 0.34 to 0.97), and improved presence (aOR 2.30; 1.75 to 3.02) and timeliness (-21.4 hours vs -8.7 hours, p<0.001) of accept note documentation. There were no significant differences in LOS or mortality., Conclusions and Relevance: Among 1658 medical patient transfers, implementing a standardised accept note was associated with improved presence and timeliness of accept note documentation, clinician-reported medical errors, failures in communication and clinical decline following transfer, suggesting that improving communication during IHT can improve patient outcomes., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2023. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Introduction: Medication organizations across the USA have adopted electronic health records, and one of the most anticipated benefits of these was improved medication safety, but alert fatigue has been a major issue., Objective: We compared the appropriateness of medication-related clinical decision support alerts triggered by two commercial applications: EPIC and Seegnal's platform., Methods: This was a retrospective comparison of two commercial applications. We provided Seegnal with deidentified inpatient, outpatient, and inpatient genetic electronic medical record (EMR)-extracted datasets for 657, 2731, and 413 patients, respectively. Seegnal then provided the alerts that would have triggered, which we compared with those triggered by EPIC in clinical care. A random sample of the alerts triggered were reviewed for appropriateness, and the positive predictive value (PPV) and negative predictive value (NPV) were calculated. We also reviewed all the inpatient and outpatient charts for patients within our cohort who were receiving ten or more concomitant medications with alerts we found to be appropriate to assess whether any adverse events had occurred and whether Seegnal's platform could have prevented them., Results: Results from EPIC and the Seegnal platform were compared based on alert load, PPV, NPV, and potential adverse events. Overall, compared with EPIC, the Seegnal platform triggered fewer alerts in the inpatient (1697 vs. 27,540), outpatient (2341 vs. 35,134), and inpatient genetic (1493 vs. 20,975) cohorts. The Seegnal platform had higher specificity in the inpatient (99 vs. 0.3%; p < 0.0001), outpatient (99 vs. 0.3%; p < 0.0001), and inpatient genetic (97.9 vs. 1.2%; p < 0.0001) groups and higher sensitivity in the inpatient (100 vs. 68.8%; p < 0.0001) and outpatient (88.6 vs.78.3%; p < 0.0001) groups but not in the inpatient genetic cohort (81 vs. 78.5%; p = 0.11). We identified 16 adverse events that occurred in the inpatient setting, 11 (69%) of which potentially could have been prevented with the Seegnal platform., Conclusions: Overall, the Seegnal platform triggered 94% fewer alerts than EPIC in the inpatient setting and 93% fewer in the outpatient setting, with much higher sensitivity and specificity. This application could substantially reduce alert fatigue and improve medication safety at the same time.

Objective: Opioid analgesics are a mainstay for acute pain management, but postoperative opioid administration has risks. We examined the prevalence, risk factors, and consequences of opioid-related adverse drug events (ORADEs) in a previously opioid-free surgical population., Methods: A retrospective, observational, cohort study using administrative, billing, clinical, and medication administration data from two hospitals. Data were collected for all adult patients who were opioid-free at admission, underwent surgery between October 1, 2015, and September 30, 2016, and received postoperative opioids. Potential ORADEs were determined based on inpatient billing codes or postoperative administration of naloxone. We determined independent predictors of ORADE development using multivariable logistic regression. We measured adjusted inpatient mortality, hospital costs, length of hospital stay, discharge destination, and readmission within 30 days for patients with and without ORADEs., Results: Among 13,389 hospitalizations where opioid-free patients had a single qualifying surgery, 12,218 (91%) received postoperative opioids and comprised the study cohort. Of these, we identified 1111 (9.1%) with a potential ORADE. Independent predictors of ORADEs included older age, several markers of disease severity, longer surgeries, and concurrent benzodiazepine use. Opioid-related adverse drug events were strongly associated with the route and duration of opioids administered postoperatively: 18% increased odds per day on intravenous opioids. In analyses adjusted for several covariates, presence of an ORADE was associated with 32% higher costs of hospitalization, 45% longer postoperative length of stay, 36% lower odds of discharge home, and 2.2 times the odds of death., Conclusions: We demonstrate a high rate and severe consequences of potential ORADEs in previously opioid-free patients receiving postoperative opioids. Knowledge of risk factors and predictors of ORADEs can help develop targeted interventions to minimize the development of these potentially dangerous and costly events., Competing Interests: J.L.S. is funded by an investigator-initiated grant from Portola Pharmaceuticals for an unrelated study. The rest of the authors disclose no conflict of interest., (Copyright © 2019 Wolters Kluwer Health, Inc. All rights reserved.)

Renin angiotensin aldosterone system inhibitors (RAASi) and diuretics are among the most frequently prescribed anti-hypertensives. Individuals with chronic kidney disease (CKD) are particularly at risk for electrolyte disturbances and kidney injury but the appropriate use of lab monitoring following RAASi or diuretic initiation is uncertain in CKD.We describe the frequency and time interval of lab monitoring during initiation of RAASi and diuretics in CKD and assess whether close lab monitoring associates with one-year risk of emergency department (ED) visit or hospitalization.We evaluated an observational cohort of 8,217 individuals with stage 3-5 non-dialysis CKD newly prescribed a RAASi (52.3%) or diuretic (47.7%) from thirty-six primary care offices affiliated with Brigham and Women's Hospital and Massachusetts General Hospital between 2009 and 2011.Overall, 3306 (40.2%) individuals did not have pre-prescription labs done within 2 weeks, and 5957 (72.5%) did not have post-prescription labs done within 2 weeks which includes 524 (6.4%) individuals without post-prescription within 1 year. Close monitoring occurred in only 1547 (20.1%) and was more likely in individuals prescribed diuretics compared to RAASi (adjusted OR 1.39; 95%CI 1.20-1.62), with CKD stage 4,5 compared with stage 3 (adjusted OR 1.47; 95%CI 1.16-1.86) and with cardiovascular disease (adjusted OR 1.42; 95%CI 1.21-1.66). Close monitoring was not associated with decreased risk of ED visit or hospitalization.Close lab monitoring during initiation of RAASi or diuretics was more common in participants with cardiovascular disease and advanced CKD suggesting physicians selected high-risk individuals for close monitoring. As nearly 80% of individuals did not receive close lab monitoring there may be value in future research on electronic physician decision tools targeted at lab monitoring.

Importance: Renin angiotensin aldosterone system inhibitors (RAASIs) benefit individuals with chronic kidney disease (CKD). Elevations in serum creatinine and potassium levels are common reasons for discontinuation of this therapy, but their incidence and risks are not well characterized in community practice., Objective: To evaluate associations of increased creatinine levels, hyperkalemia, and therapy continuation with the risk of emergency department (ED) visits, hospitalizations, and mortality within 1 year after RAASI therapy initiation in individuals with CKD., Design, Setting, and Participants: This prospective cohort study included 4661 individuals with nondialysis CKD newly prescribed a RAASI or a diuretic who were treated at 36 outpatient primary care offices affiliated with Brigham & Women's Hospital and Massachusetts General Hospital, Boston, from January 1, 2009, through December 31, 2011. Individuals receiving a new prescription for a diuretic were used to provide context. All participants had a baseline measure of renal function and at least 1 follow-up measurement of creatinine and potassium levels within 90 days of the prescription. Data were analyzed from January 1, 2009, through December 31, 2012., Exposures: Changes in creatinine and potassium levels within 90 days after the prescription date and therapy discontinuation., Main Outcomes and Measures: Emergency department visits, hospitalizations, and mortality within 1 year., Results: A total of 4661 individuals were included in the analysis (2506 [53.8%] women; mean [SD] age, 71 [14]; 3931 [84.3%] white; and 4198 [90.1%] with CKD stage 3). Of these, 2354 individuals (50.5%) received RAASIs and 2307 (49.5%) received diuretics. Creatinine level increase of at least 30% after RAASI therapy initiation was found in 158 of 2354 individuals (6.7%); hyperkalemia of greater than 5.0 mEq/L, in 251 of 2354 (10.7%). Increases in creatinine level of at least 30% (unadjusted odds ratio [OR], 1.40; 95% CI, 0.89-2.21), hyperkalemia (unadjusted OR, 1.15; 95% CI, 0.64-2.06), and therapy discontinuation (unadjusted OR, 1.01; 95% CI, 0.71-1.46) were not associated with ED visits or hospitalizations, which was consistent with results from competing risk analyses. Initial increases in creatinine level of at least 30% were associated with mortality in the total cohort (adjusted OR [aOR], 2.17; 95% CI, 1.45-3.25). However, the effect was only independent for diuretics (aOR, 2.27; 95% CI, 1.41-3.66) and not for RAASIs (aOR, 1.82; 95% CI, 0.83-3.99)., Conclusions and Relevance: Acute creatinine and potassium level disturbances after initiation of RAASI therapy in individuals with CKD appear to be sustained often often not sustained and not associated with ED visits or hospitalizations, despite therapy continuation. Findings from this study suggest that increases in creatinine level were independently associated with mortality among individuals prescribed diuretics but not RAASIs. Structured laboratory monitoring during RAASI therapy initiation may guide appropriate continuation of therapy in the outpatient setting.

Objective: To define the types and numbers of inpatient clinical decision support alerts, measure the frequency with which they are overridden, and describe providers' reasons for overriding them and the appropriateness of those reasons., Materials and Methods: We conducted a cross-sectional study of medication-related clinical decision support alerts over a 3-year period at a 793-bed tertiary-care teaching institution. We measured the rate of alert overrides, the rate of overrides by alert type, the reasons cited for overrides, and the appropriateness of those reasons., Results: Overall, 73.3% of patient allergy, drug-drug interaction, and duplicate drug alerts were overridden, though the rate of overrides varied by alert type (P < .0001). About 60% of overrides were appropriate, and that proportion also varied by alert type (P < .0001). Few overrides of renal- (2.2%) or age-based (26.4%) medication substitutions were appropriate, while most duplicate drug (98%), patient allergy (96.5%), and formulary substitution (82.5%) alerts were appropriate., Discussion: Despite warnings of potential significant harm, certain categories of alert overrides were inappropriate >75% of the time. The vast majority of duplicate drug, patient allergy, and formulary substitution alerts were appropriate, suggesting that these categories of alerts might be good targets for refinement to reduce alert fatigue., Conclusion: Almost three-quarters of alerts were overridden, and 40% of the overrides were not appropriate. Future research should optimize alert types and frequencies to increase their clinical relevance, reducing alert fatigue so that important alerts are not inappropriately overridden.

Introduction: Drug-allergy interaction (DAI) alerts are generated when a known adverse sensitivity-inducing substance is prescribed. A recent study at our institution showed that providers overrode most DAI alerts, including those that warned against potentially life-threatening 'anaphylaxis'., Objective: The aim of this study was to determine the rate of anaphylaxis overrides, the reasons for these overrides, whether the overrides were appropriate, and if harm occurred from overrides., Methods: All DAI alerts, with a reaction of 'anaphylaxis', were analysed for inpatients and outpatients within our health system between January 2009 and December 2011. Only alerts that were triggered by 'definite' alerts (i.e. same ordered medication as documented allergen) were included. Patient charts were reviewed to assess the appropriateness of overrides and potential harm, according to a predetermined set of criteria., Results: A total of 202 inpatient and 16 outpatient alerts met the inclusion criteria. The rate of overrides for 'definite' anaphylaxis DAI alerts was high (inpatient: n = 93, 46.0%; outpatient: n = 11, 68.8%) but appropriate for most overrides in the inpatient (n = 78, 83.9%) and outpatient settings (n = 11, 100%). The most common override reasons in the inpatient and outpatient settings were 'administer per desensitization protocol' (n = 64, 31.7%) and 'patient does not have this allergy' (n = 7, 63.6%), respectively. No harm was associated with overrides in either setting, particularly because many medications were not administered., Conclusions: Overrides of 'definite' anaphylaxis DAI alerts were common and often appropriate. Most overrides were due to desensitizations. Allergy reconciliation for patients could further improve critical decision support.

Background: Electronic health records (EHRs) with clinical decision support (CDS) have shown to be effective at improving patient safety. Despite this, alerts delivered as part of CDS are overridden frequently, which is of concern in the critical care population as this group may have an increased risk of harm. Our organization recently transitioned from an internally-developed EHR to a commercial system. Data comparing various EHR systems, especially after transitions between EHRs, are needed to identify areas for improvement., Objectives: To compare the two systems and identify areas for potential improvement with the new commercial system at a single institution., Methods: Overridden medication-related CDS alerts were included from October to December of the systems' respective years (legacy, 2011; commercial, 2015), restricted to three intensive care units. The two systems were compared with regards to CDS presentation and override rates for four types of CDS: drug-allergy, drug-drug interaction (DDI), geriatric and renal alerts. A post hoc analysis to evaluate for adverse drug events (ADEs) potentially resulting from overridden alerts was performed for 'contraindicated' DDIs via chart review., Results: There was a significant increase in provider exposure to alerts and alert overrides in the commercial system (commercial: n=5,535; legacy: n=1,030). Rates of overrides were higher for the allergy and DDI alerts (p<0.001) in the commercial system. Geriatric and renal alerts were significantly different in incidence and presentation between the two systems. No ADEs were identified in an analysis of 43 overridden contraindicated DDI alerts., Conclusions: The vendor system had much higher rates of both alerts and overrides, although we did not find evidence of harm in a review of DDIs which were overridden. We propose recommendations for improving our current system which may be helpful to other similar institutions; improving both alert presentation and the underlying knowledge base appear important.

Purpose: Medication-related clinical decision support (CDS) has been identified as a method to improve patient outcomes but is historically frequently overridden and may be inappropriately so. Patients in the intensive care unit (ICU) are at a higher risk of harm from adverse drug events (ADEs) and these overrides may increase patient harm. The objective of this study is to determine appropriateness of overridden medication-related CDS overrides in the ICU., Materials and Methods: We evaluated overridden medication-related alerts of four alert categories from January 2009 to December 2011. The primary outcome was the appropriateness of a random sample of overrides based on predetermined criteria. Secondary outcomes included the incidence of adverse drug events (ADEs) that resulted from the overridden alert., Results: A total of 47,449 overridden alerts were included for evaluation. The appropriateness rate for overridden alerts varied by alert category (allergy: 94%, drug-drug interaction: 84%, geriatric: 57%, renal: 27%). A total of seven actual ADEs were identified in the random sample and where the medication(s) was administered (n=366), with an increased risk of ADEs associated with inappropriately overridden alerts (p=0.0078)., Conclusions: The appropriateness of medication-related clinical decision support overrides in the ICU varied substantially by the type of alert. Inappropriately overridden alerts were associated with an increased risk of ADEs compared to appropriately overridden alerts., (Copyright © 2017. Published by Elsevier Inc.)

Objectives: To evaluate how often and why providers overrode drug allergy alerts in both the inpatient and outpatient settings., Design: A cross-sectional observational study of drug allergy alerts generated over a 3-year period between 1 January 2009 and 31 December 2011., Setting: A 793-bed tertiary care teaching affiliate of Harvard Medical School and 36 primary care practices., Participants: Drug allergy alerts were displayed for a total of 29 420 patients across both settings., Main Outcome Measures: Proportion of drug allergy alerts displayed and overridden, proportion of appropriate overrides, proportion of overrides in each medication class, different reasons for overriding and types of reactions overridden., Results: A total of 158 023 drug allergy alerts were displayed, 131 615 (83%) in the inpatient setting and 26 408 (17%) in the outpatient setting; 128 157 (81%) of which were overridden. A random sample of inpatient (n=200, 0.19%) and outpatient (n=50, 0.25%) alert overrides were screened for appropriateness, with >96% considered appropriate. Alerts for some drug classes, such as 'non-antibiotic sulfonamides', were overridden for >81% of prescriptions in both settings. The most common override reason was patient has taken previously without allergic reaction . In the inpatient setting alone, 70.9% of alerts that warned against the risk of anaphylaxis were overridden., Conclusions: The information contained in patients' drug allergy lists needs to be regularly updated. Most of the drug allergy alerts were overridden, with the majority of alert overrides in the subsample considered appropriate. Some of the rules for these alerts should be carefully reviewed and modified, or removed. Further research is needed to understand providers' overriding of alerts that warned against the risk of 'anaphylaxis', which are more concerning with respect to patient safety., (Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://www.bmj.com/company/products-services/rights-and-licensing/.)

Background: The Joint Commission requires hospitals to formally review formulary medications at least annually based on new clinical information. Although review of nonformulary medication (NFM) use is not required, frequent and inappropriate use of NFMs has the potential to increase hospital costs, negatively affect quality of care, and increase medication errors. Limited resources may restrict an institution's ability to review NFM use in addition to the required annual formulary review. NFM use at Brigham and Women's Hospital (BWH) was reviewed to provide insight on how to best direct an NFM review that is both effective and efficient. How an NFM review may negatively affect cost, quality of care, and medication errors is also inferred., Methods: All approved NFM requests between 2009 and 2012 from Brigham and Women's Hospital's computerized provider order entry system were extracted and categorized according to the American Hospital Formulary Service (AHFS) Pharmacologic-Therapeutic Classification System., Results: Of the 15,356,016 new medication orders, there were 223,266 NFM approvals for 433 unique NFMs. NFMs were categorized into 91 AHFS, 14 combination, and 4 "Others" classes. Twenty-five AHFS Classes accounted for approximately the top 90% of all NFM approvals, and the top 2 NFMs in each class accounted for a majority of the NFM approvals., Conclusion: Only a few classes of medications and a few medications within each class accounted for most of the NFM use at BWH. Targeting review of the most frequently used NFMs in each class may be a feasible strategy to reviewing NFMs annually that is both effective and efficient in optimizing formulary benefits., (Copyright © 2016 The Joint Commission. Published by Elsevier Inc. All rights reserved.)

Background: Experts suggest that formulary alerts at the time of medication order entry are the most effective form of clinical decision support to automate formulary management., Objective: Our objectives were to quantify the frequency of inappropriate nonformulary medication (NFM) alert overrides in the inpatient setting and provide insight on how the design of formulary alerts could be improved., Methods: Alert overrides of the top 11 (n = 206) most-utilized and highest-costing NFMs, from January 1 to December 31, 2012, were randomly selected for appropriateness evaluation. Using an empirically developed appropriateness algorithm, appropriateness of NFM alert overrides was assessed by 2 pharmacists via chart review. Appropriateness agreement of overrides was assessed with a Cohen's kappa. We also assessed which types of NFMs were most likely to be inappropriately overridden, the override reasons that were disproportionately provided in the inappropriate overrides, and the specific reasons the overrides were considered inappropriate., Results: Approximately 17.2% (n = 35.4/206) of NFM alerts were inappropriately overridden. Non-oral NFM alerts were more likely to be inappropriately overridden compared to orals. Alerts overridden with "blank" reasons were more likely to be inappropriate. The failure to first try a formulary alternative was the most common reason for alerts being overridden inappropriately., Conclusion: Approximately 1 in 5 NFM alert overrides are overridden inappropriately. Future research should evaluate the impact of mandating a valid override reason and adding a list of formulary alternatives to each NFM alert; we speculate these NFM alert features may decrease the frequency of inappropriate overrides., (© The Author 2016. Published by Oxford University Press on behalf of the American Medical Informatics Association. All rights reserved. For Permissions, please email: journals.permissions@oup.com.)

Background: Improving the quality of prescribing and appropriate handling of alerts remains a challenge for design and implementation of clinical decision support (CDS) and comparatively little is known about the effects that provider characteristics have on how providers respond to medication alerts., Objectives: To investigate the relationship between provider characteristics and their response to medication alerts in the outpatient setting., Design and Participants: Retrospective observational study using a prescription log from the automated electronic outpatient system for each of 478 providers using the system at primary care practices affiliated with 2 teaching hospitals, from 2009 to 2011 for six types of alerts. Provider characteristics were obtained from the hospital credentialing system and the Massachusetts Board of Registration in Medicine., Main Measures: Override rates per 100 prescriptions and 100 alerts., Results: The providers' mean override rates per 100 prescriptions and per 100 alerts were 0.52 (95% confidence interval (CI), 0.46-0.58) and 0.42 (95% CI, 0.38-0.44) respectively. The physicians (n=422) on average overrode drug alerts with rates of 0.48 per 100 drugs and 0.44 per 100 warnings. Univariate analysis revealed that six physician characteristics (physician type, age, number of encounters, medical school ranking, residency hospital ranking, and acceptance of Medicaid) were significantly related to the override rate. Multiple regression showed that house staff were more likely to override than staff physicians (p<0.001), physicians with fewer than 13 average daily encounters were more likely to override than others with more than 13 encounters (p (range), <0.001-0.05), and graduates of the top 5 medical schools were more likely to override than the others (p=0.04). All six predictors together explained 30% and 50% of the variance in override rates, respectively., Conclusions: Consideration of six specific physician characteristics may help inform interventions to improve prescriber decision-making., (Copyright © 2015 Elsevier Ireland Ltd. All rights reserved.)

Objective: To assses the relationship between methods of documenting visit notes and note quality for primary care providers (PCPs) and specialists, and to determine the factors that contribute to higher quality notes for two chronic diseases., Methods: Retrospective chart review of visit notes at two academic medical centers. Two physicians rated the subjective quality of content areas of the note (vital signs, medications, lifestyle, labs, symptoms, assessment & plan), overall quality, and completed the 9 item Physician Documentation Quality Instrument (PDQI-9). We evaluated quality ratings in relation to the primary method of documentation (templates, free-form or dictation) for both PCPs and specialists. A one factor analysis of variance test was used to examine differences in mean quality scores among the methods., Results: A total of 112 physicians, 71 primary care physicians (PCP) and 41 specialists, wrote 240 notes. For specialists, templated notes had the highest overall quality scores (p≤0.001) while for PCPs, there was no statistically significant difference in overall quality score. For PCPs, free form received higher quality ratings on vital signs (p = 0.01), labs (p = 0.002), and lifestyle (p = 0.002) than other methods; templated notes had a higher rating on medications (p≤0.001). For specialists, templated notes received higher ratings on vital signs, labs, lifestyle and medications (p = 0.001)., Discussion: There was no significant difference in subjective quality of visit notes written using free-form documentation, dictation or templates for PCPs. The subjective quality rating of templated notes was higher than that of dictated notes for specialists., Conclusion: As there is wide variation in physician documentation methods, and no significant difference in note quality between methods, recommending one approach for all physicians may not deliver optimal results.

Background: Electronic prescribing is increasingly used, in part because of government incentives for its use. Many of its benefits come from clinical decision support (CDS), but often too many alerts are displayed, resulting in alert fatigue., Objective: To characterize the override rates for medication-related CDS alerts in the outpatient setting, the reasons cited for overrides at the time of prescribing, and the appropriateness of overrides., Methods: We measured CDS alert override rates and the coded reasons for overrides cited by providers at the time of prescribing. Our primary outcome was the rate of CDS alert overrides; our secondary outcomes were the rate of overrides by alert type, reasons cited for overrides at the time of prescribing, and override appropriateness for a subset of 600 alert overrides. Through detailed chart reviews of alert override cases, and selective literature review, we developed appropriateness criteria for each alert type, which were modified iteratively as necessary until consensus was reached on all criteria., Results: We reviewed 157,483 CDS alerts (7.9% alert rate) on 2,004,069 medication orders during the study period. 82,889 (52.6%) of alerts were overridden. The most common alerts were duplicate drug (33.1%), patient allergy (16.8%), and drug-drug interactions (15.8%). The most likely alerts to be overridden were formulary substitutions (85.0%), age-based recommendations (79.0%), renal recommendations (78.0%), and patient allergies (77.4%). An average of 53% of overrides were classified as appropriate, and rates of appropriateness varied by alert type (p<0.0001) from 12% for renal recommendations to 92% for patient allergies., Discussion: About half of CDS alerts were overridden by providers and about half of the overrides were classified as appropriate, but the likelihood of overriding an alert varied widely by alert type. Refinement of these alerts has the potential to improve the relevance of alerts and reduce alert fatigue.

Background: The Food and Drug Administration issues black-box warnings (BBWs) regarding medications with serious risks, yet physician adherence to the warnings is low., Methods: We evaluated the impact of delivering BBW-based alerts about drug-drug, drug-disease, and drug-laboratory interactions for prescription medications in outpatients in an electronic health record with clinical decision support. We compared the frequency of non-adherence to all BBWs about drug-drug, drug-disease, and drug-laboratory interactions for 30 drugs/drug classes, and by individual drugs/drug groups with BBWs between the pre- and post-intervention periods. We used multivariate analysis to identify independent risk factors for non-adherence to BBWs., Results: There was a slightly higher frequency of non-adherence to BBWs after the intervention (4.8% vs. 5.1%, p=0.045). In multivariate analyses, after adjustment for patient and provider characteristics and site of care, medications prescribed during the pre-intervention period were less likely to violate BBWs compared to those prescribed during the post-intervention period (OR 0.67, 95% CI, 0.47-0.96). However, black-box warning violations did decrease after the intervention for BBWs about drug-drug interactions (6.1% vs. 1.8%, p<0.0001) and drug-pregnancy interactions (5.1% vs. 3.6%, p=0.01)., Conclusions: Ambulatory care computerized order entry with prescribing alerts about BBWs did not improve clinicians' overall adherence to BBWs, though it did improve adherence for specific clinically important subcategories., (Copyright © 2010 John Wiley & Sons, Ltd.)

Objective: Recommendations for routine laboratory monitoring to reduce the risk of adverse medication events are not consistently followed. We evaluated the impact of electronic reminders delivered to primary care physicians on rates of appropriate routine medication laboratory monitoring., Design: We enrolled 303 primary care physicians caring for 1,922 patients across 20 ambulatory clinics that had at least one overdue routine laboratory test for a given medication between January and June 2004. Clinics were randomized so that physicians received either usual care or electronic reminders at the time of office visits focused on potassium, creatinine, liver function, thyroid function, and therapeutic drug levels., Measurements: Primary outcomes were the receipt of recommended laboratory monitoring within 14 days following an outpatient clinic visit. The effect of the intervention was assessed for each reminder after adjusting for clustering within clinics, as well as patient and provider characteristics., Results: Medication-laboratory monitoring non-compliance ranged from 1.6% (potassium monitoring with potassium-supplement use) to 6.3% (liver function monitoring with HMG CoA Reductase Inhibitor use). Rates of appropriate laboratory monitoring following an outpatient visit ranged from 14% (therapeutic drug levels) to 64% (potassium monitoring with potassium-sparing diuretic use). Reminders for appropriate laboratory monitoring had no impact on rates of receiving appropriate testing for creatinine, potassium, liver function, renal function, or therapeutic drug level monitoring., Conclusion: We identified high rates of appropriate laboratory monitoring, and electronic reminders did not significantly improve these monitoring rates. Future studies should focus on settings with lower baseline adherence rates and alternate drug-laboratory combinations.

Background: Few data are available regarding the prevalence of potentially dangerous drug-drug, drug-laboratory, and drug-disease interactions among outpatients. Our objectives were to determine how frequently clinicians prescribe drugs in violation of black box warnings for these issues and to determine how frequently such prescribing results in harm., Methods: In an observational study of 51 outpatient practices using an electronic health record, we measured the frequency with which patients received prescriptions in violation of black box warnings for drug-drug, drug-laboratory, and/or drug-disease interactions. We performed medical record reviews in a sample of patients to detect adverse drug events. Multivariate analysis was conducted to assess the relationship of prescribing in violation of black box warnings to patient and clinician characteristics, adjusting for potential confounders and clustering., Results: Of 324 548 outpatients who received a medication in 2002, 2354 (0.7%) received a prescription in violation of a black box warning. After adjustment, receipt of medication in violation of a black box warning was more likely when patients were 75 years or older or female. The number of medications taken, the number of medical problems, and the site of care were also associated with violations. Less than 1% of patients who received a drug in violation of a black box warning had an adverse drug event as a result., Conclusions: About 7 in 1000 outpatients received a prescription violating a black box warning. Few incidents resulted in detectable harm.

Computerized drug prescribing alerts can improve patient safety, but are often overridden because of poor specificity and alert overload. We developed a selective knowledge base of only clinically significant drug alerts and designated only critical-high severity alerts to be interruptive to clinician workflow (a tiered approach). Using this approach, we were able to achieve a 67% clinician accept rate for ambulatory computerized prescribing alerts.

Rationale, Aims and Objectives: To identify potential factors leading to discontinuation of angiotensin-converting enzyme (ACE) inhibitors because of adverse drug events., Methods: Retrospective cohort study was conducted at outpatient clinics affiliated with an urban tertiary care hospital. ACE inhibitors were administered to 2225 consecutive outpatients., Results: In 19% of the total cohort, ACE inhibitors were discontinued because of adverse drug events. Cox proportional hazard model identified the following independent risk factors for discontinuation because of adverse drug events: age, female gender, ethnicity other than African American or Latino, no history of previous ACE inhibitor use, history of cough caused by another ACE inhibitor, hypertension, anxiety or depression, no hemodialysis, and elevated creatinine. History of smoking was shown to be a risk factor for cough [hazard ratio (HR): 2.5; 95% confidence interval (CI): 1.1-5.7], angioedema (HR: 2.7; 95% CI: 1.1-7.0), and hyperkalaemia (HR: 5.4; 95% CI: 1.3-23.2). History of ACE inhibitor-induced cough was not only a risk factor for cough (HR: 12.9; 95% CI: 7.5-22.3) but also for angioedema (HR: 9.1; 95% CI: 2.1-39.9). Patients with creatinine > or = 1.6 mg dL(-1) were likely to discontinue ACE inhibitors because of renal dysfunction (HR: 4.7; 95% CI: 1.5-12.7) and hyperkalaemia (HR: 10.9; 95% CI: 3.1-39.0). East Asians were more likely to develop cough (HR: 2.5; 95% CI: 1.1-5.7) and hyperkalaemia (HR: 80.3; 95% CI: 5.4-1190) and African Americans to develop angioedema (HR: 3.5; 95% CI: 1.3-8.9)., Conclusions: Although further validation is necessary, these risk factors should help doctors identify patients with elevated risk for adverse drug events because of ACE inhibitors.

Background: Angiotensin-converting enzyme inhibitors are effective for many cardiovascular diseases and are widely prescribed, but cough sometimes necessitates their withdrawal., Objective: To develop and validate a model that predicts, by using information available at first prescription, whether a patient will develop cough within 6 months., Design: Retrospective cohort study with derivation and validation sets., Setting: Outpatient clinics affiliated with an urban tertiary care hospital., Patients: Clinical data were collected from electronic charts. The derivation set included 1125 patients and the validation set included 567 patients., Interventions: None., Measurements: Angiotensin-converting enzyme inhibitor-induced cough assessed by predetermined criteria., Results: In the total cohort, 12% of patients developed angiotensin-converting enzyme inhibitor-induced cough. Independent multivariate predictors of cough were older age, female gender, non-African American (with East Asian having highest risk), no history of previous angiotensin-converting enzyme inhibitor use, and history of cough due to another angiotensin-converting enzyme inhibitor. Patients with a history of angiotensin-converting enzyme inhibitor-induced cough were 29 times more likely to develop a cough than those without this history. These factors were used to develop a model stratifying patients into 4 risk groups. In the derivation set, low-risk, average-risk, intermediate-risk, and high-risk groups had a 6%, 9%, 22%, and 55% probability of cough, respectively. In the validation set, 4%, 14%, 20%, and 60% of patients in these 4 groups developed cough, respectively., Conclusions: This model may help clinicians predict the likelihood of a particular patient developing cough from an angiotensin-converting enzyme inhibitor at the time of prescribing, and may also assist with subsequent clinical decisions.

Objective: Detecting adverse events is pivotal for measuring and improving medical safety, yet current techniques discourage routine screening. The authors hypothesized that discharge summaries would include information on adverse events, and they developed and evaluated an electronic method for screening medical discharge summaries for adverse events., Design: A cohort study including 424 randomly selected admissions to the medical services of an academic medical center was conducted between January and July 2000. The authors developed a computerized screening tool that searched free-text discharge summaries for trigger words representing possible adverse events., Measurements: All discharge summaries with a trigger word present underwent chart review by two independent physician reviewers. The presence of adverse events was assessed using structured implicit judgment. A random sample of discharge summaries without trigger words also was reviewed., Results: Fifty-nine percent (251 of 424) of the discharge summaries contained trigger words. Based on discharge summary review, 44.8% (327 of 730) of the alerted trigger words indicated a possible adverse event. After medical record review, the tool detected 131 adverse events. The sensitivity and specificity of the screening tool were 69% and 48%, respectively. The positive predictive value of the tool was 52%., Conclusion: Medical discharge summaries contain information regarding adverse events. Electronic screening of discharge summaries for adverse events using keyword searches is feasible but thus far has poor specificity. Nonetheless, computerized clinical narrative screening methods could potentially offer researchers and quality managers a means to routinely detect adverse events.

Rationale, Aims and Objectives: Diagnostic abdominal imaging is frequently performed in hospitalized patients to assess the cause of abnormal liver function tests (LFTs). We undertook this study to assess whether the extent and severity of LFTs abnormalities predicted the yield of inpatient imaging., Methods: We retrospectively reviewed inpatients' abdominal imaging studies performed for abnormal LFTs during a 27 month period. Imaging results were matched to LFTs performed during a 5 day collection window surrounding the image request date. Five LFTs were categorized by severity of abnormality and were then collapsed into three classes based on pathophysiology., Results: Among 759 imaging studies completed for the indication of abnormal LFTs, 196 (26%) were positive (abnormal and explained the abnormal LFTs). Among the LFT classes, severity of laboratory test abnormality correlated with positive imaging examinations yield only for the transaminases: 18% for the normal-mildly abnormal transaminases compared with 31% for moderately-severely abnormal transaminases. The number of abnormal LFT classes per study correlated only slightly better: 21% of patients with none or one abnormal LFT class had a positive imaging study compared with 35% of patients with all three abnormal LFT classes., Conclusions: The yield of inpatient abdominal imaging for abnormal LFTs correlates only weakly with both the severity and the extent of different abnormal LFTs. Further research is needed to define the optimal imaging strategies for evaluating inpatients with suspected hepatobiliary disease.

Background: Abdominal cross-sectional imaging is often performed to evaluate abnormal liver function test (LFT) results in hospitalized patients. However, few data are available regarding the yield and usefulness of imaging inpatients for the indication of abnormal LFT results, the process of requesting abdominal imaging studies, or the response to their findings., Methods: We retrospectively reviewed abdominal imaging scans that were obtained during a 27-month period. We matched the imaging studies done with the indication of abnormal LFT results; all scans were requested using computerized physician order entry. Reports were coded for interpretation and associated process step results. To determine the usefulness of the imaging studies, a random sample of patient charts with positively coded imaging studies were reviewed. Imaging examinations were considered useful if they provided new diagnostic information and/or changed subsequent patient care., Results: Of 6494 abdominal imaging studies, 856 were performed for the indication of abnormal LFT results and matched to both image reports and laboratory results. Report coding judged 37% of interpretations as clinically significant, including 27% with "positive" (abnormal results and explain the abnormal LFT results) examinations. Among the positive examinations, the most common diagnoses were biliary obstruction (25%), cholecystitis (21%), malignancy (20%), and cirrhosis (14%). Positively coded reports provided new clinical information in 63% of these studies and changed patient care in 42% of cases. Process measures assessed provision of additional information to and from radiologists (69% and 8%, respectively) and the frequency with which the findings of current abdominal imaging studies were compared with those of prior studies (59%)., Conclusion: Abdominal cross-sectional imaging studies performed on inpatients with abnormal LFT results had a high diagnostic yield and frequently changed patient care.

As part of a project to develop knowledge-based reminders for the outpatient setting, we developed a process to help maintain the quality of the knowledge base. The knowledge engineering process involved many parties, including several domain experts, a knowledge engineer, and a programmer and a process was necessary to assure that information transfer among individuals did not become confused. An MS Access database was created to store, among other data, textual versions of the rules as they evolved over time. In a 9-month period 36 rules were entered into the database. Of those, 17 are still active in their original form. The remaining 19 underwent various types of modifications; these changes were tracked in the database. Processes and tools to maintain knowledge bases are necessary if the benefits of clinical decision support systems are to be realized and investments in knowledge engineering are to be protected.

We developed an application that allowed patients coming to the clinic to review on a paper form their computerized health maintenance, medication, and allergy data. The patient could edit the paper form and the physician then could enter the new data into the database. We implemented the system in 4 clinics (17 MDs) To evaluate the system, we reviewed 80 forms from one physician's patients to determine how often patients provided new data. We also sent questionnaires to the physicians asking for their estimates of how often there was new data and for their impression of the system. We interviewed secretaries in the clinics about logistical issues. Of the 80 forms, 29 (36%) had new data; 28% had new health maintenance data and 19% had new medication data. The 7 physicians who responded to the questionnaire estimated that new health maintenance data were present on 22% of the forms. The physicians who responded to the questionnaire felt the system was useful. The secretaries said that managing the paper flow in the clinic was often unwieldy and in some clinics, the system has been abandoned or is used intermittently. Having patients review their data is one avenue to improving the accuracy of computerized records.