Unintended Effects of a Computerized Physician Order Entry Nearly Hard-Stop Alert to Prevent a Drug Interaction

Center for Clinical Epidemiology and Biostatistics, University of Pennsylvania School of Medicine, Philadelphia, PA 19104-6021, USA.
Archives of internal medicine (Impact Factor: 17.33). 09/2010; 170(17):1578-83. DOI: 10.1001/archinternmed.2010.324
Source: PubMed


The effectiveness of computerized physician order entry (CPOE) systems has been modest, largely because clinicians frequently override electronic alerts.
To evaluate the effectiveness of a nearly "hard stop" CPOE prescribing alert intended to reduce concomitant orders for warfarin and trimethoprim-sulfamethoxazole, a randomized clinical trial was conducted at 2 academic medical centers in Philadelphia, Pennsylvania. A total of 1981 clinicians were assigned to either an intervention group receiving a nearly hard stop alert or a control group receiving the standard practice. The study duration was August 9, 2006, through February 13, 2007.
The proportion of desired responses (ie, not reordering the alert-triggering drug within 10 minutes of firing) was 57.2% (111 of 194 hard stop alerts) in the intervention group and 13.5% (20 of 148) in the control group (adjusted odds ratio, 0.12; 95% confidence interval, 0.045-0.33). However, the study was terminated early because of 4 unintended consequences identified among patients in the intervention group: a delay of treatment with trimethoprim-sulfamethoxazole in 2 patients and a delay of treatment with warfarin in another 2 patients.
An electronic hard stop alert as part of an inpatient CPOE system seemed to be extremely effective in changing prescribing. However, this intervention precipitated clinically important treatment delays in 4 patients who needed immediate drug therapy. These results illustrate the importance of formal evaluation and monitoring for unintended consequences of programmatic interventions intended to improve prescribing habits. Identifier: NCT00870298.

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    • "Some suggestions include reducing the number of alerts or making them effective by reflecting the nature of the patient condition they are supporting. Other studies suggest the consideration of the context of disease and care, age and function of the end user (e.g., health care professionals) as well as other contextual parameters [25]. Indeed, a number of review articles in health care research note that although there have been enough studies on alarm fatigues, the relevant contextual and situational analysis of alarms is lacking—often leaving the practitioners to ignore or manage the alert related issues internally (see [5] [13] [26]). "
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