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Doctors override automated alerts on potential drug interactions

To reduce medication errors, many hospitals have adopted computerized order entry systems. These systems let clinicians enter drug orders electronically, and alert messages appear when a drug could negatively interact with another medication in the patient's drug portfolio. Clinicians can opt to override the alert, appending their rationale to assure the receiving pharmacist that possible adverse drug interactions were considered.

Amy J. Grizzle, Pharm.D., and colleagues conducted a study at six Veterans Affairs (VA) Medical Centers for one year (July 1, 2003, to June 30, 2004) to examine how often clinicians override drug interaction alerts and the reasons offered for overrides. The VA classifies interactions into two levels of severity: critical and significant. Clinicians are required to type in a reason when they override critical interaction alerts but typically not for significant interaction alerts.

Of the 291,890 overrides in the system, 72 percent were for critical alerts. Twenty percent of the override reasons for critical interaction, including no responses, were rated as useful. An override reason was not provided for 53 percent of the critical interaction alerts. When override reasons were documented for critical interaction alerts, only 43 percent of the reasons were determined useful to pharmacists to gauge clinical appropriateness and risk to the patient. For significant interaction alerts, half the reasons were useful. Overall, reasons for overrides were not provided 84 percent of the time.

The researchers offer alert fatigue as one explanation for why prescribers overrode the system. For example, at times, alerts appear for medicines that have no interactions, such as topical and oral drug combinations. (This has been remedied in the VA system.) Prescribers may also see the alerts as insignificant and annoying. In fact, some of the typed-in reasons for overrides included sarcasm.

This study was funded in part by the Agency for Healthcare Research and Quality (HS10385).

See "Reasons provided by prescribers when overriding drug-drug interaction alerts," by Dr. Grizzle, Maysaa H. Mahmood, M.S., Yu Ko, M.S., and others in the October 2007 American Journal of Managed Care 13(10), pp. 573-580.

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