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Objective The study sought to determine availability and use of structured override reasons for drug-drug interaction (DDI) alerts in electronic health records. Materials and Methods We collected data on DDI alerts and override reasons from 10 clinical sites across the United States using a variety of electronic health records. We used a multistage iterative card sort method to categorize the override reasons from all sites and identified best practices. Results Our methodology established 177 unique override reasons across the 10 sites. The number of coded override reasons at each site ranged from 3 to 100. Many sites offered override reasons not relevant to DDIs. Twelve categories of override reasons were identified. Three categories accounted for 78% of all overrides: “will monitor or take precautions,” “not clinically significant,” and “benefit outweighs risk.” Discussion We found wide variability in override reasons between sites and many opportunities to improve alerts. Some override reasons were irrelevant to DDIs. Many override reasons attested to a future action (eg, decreasing a dose or ordering monitoring tests), which requires an additional step after the alert is overridden, unless the alert is made actionable. Some override reasons deferred to another party, although override reasons often are not visible to other users. Many override reasons stated that the alert was inaccurate, suggesting that specificity of alerts could be improved. Conclusions Organizations should improve the options available to providers who choose to override DDI alerts. DDI alerting systems should be actionable and alerts should be tailored to the patient and drug pairs.

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INCE PUBLICATION OF TO ERR IS HUMAN, ELECTRONIC health records (EHRs) and related health information technologies have been promoted as means to improve patient safety. This promise remains largely unfulfilled. For instance, whereas EHRs with clinical decision support (CDS) interventions integrated into computerized physician order entry (CPOE) have measurably improved clinicians' performance on process metrics, 1 their effect on patient outcomes remains unconfirmed. 2 Recently, the US Department of Health and Human Services (DHHS) launched "Partnership for Patients: Better Care, Lower Costs" by committing $1 billion to improve safety. 3 Meanwhile, EHR vendors and health care organizations have focused considerable effort on meeting standards for "meaningful use" of EHRs as required by the DHHS for incentive payments.Each year, the Joint Commission issues a concise National Patient Safety Goal (NPSG) advisory identifying the highest-priority topics for quality care. 4 Ideally, addressing the NPSGs should be incorporated into the EHR certification process, requiring each vendor to specifically engineer targeted solutions and each organization to carefully implement and use these systems to improve safety. For 2011, the NPSG priorities for hospital quality improvement initiatives are patient identification, staff communication, medication labeling, infection control practices, medication reconciliation and interactions, and mitigation of suicide risks.Electronic health records, along with CPOE, CDS, and bar code medication administration (BCMA), if designed, developed, implemented, and used correctly, potentially play critical roles in addressing these safety goals. In this Commentary, we provide an overview of these goals, current EHR solutions and shortcomings, and potential for improvement. Safe Use of MedicationsElectronic health records with CDS and BCMA integrated into the medication order-verification-administration work-See also p 90.

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Background Targeted temperature management (TTM) for out-of-hospital cardiac arrest is associated with improved functional survival and is a class I recommendation in resuscitation guidelines. However, patterns of utilization of TTM and adherence to recommended TTM guidelines in contemporary practice are unknown. Methods and Results In a multicenter, prospective cohort of consecutive adults with non-traumatic out-of-hospital cardiac arrest in the Resuscitation Outcomes Consortium in 2012 to 2015, we identified all adults (≥18 years) who were potential candidates for TTM. Of 37 898 out-of-hospital cardiac arrest patients at 186 hospitals across 10 Resuscitation Outcomes Consortium sites, 8313 survived for ≥4 hours after hospital arrival, of which, 2878 (34.6%) received TTM. Mean age was 61.5 years and 36.3% were women. Median hospital rate of TTM use was 27% (interquartile range [IQR]: 14%, 45%), with an over 2-fold difference across sites after accounting for differences in presentation characteristics (median odds ratio, 2.10 [1.83–2.26]). Notably, TTM utilization decreased during the study period (57.5% [2012] to 26.5% [2015], P <0.001) including among shockable out-of-hospital cardiac arrest (73.4% to 46.3%, P <0.001). When administered, the median rate of deviation from one or more recommended practices was 60% (IQR: 40%, 78%). The median rate for delayed onset of TTM was 13% (IQR: 0%, 25%), varying by 70% for identical patients across 2 randomly chosen hospitals (median odds ratio 1.70 [1.39–1.97]). Similarly, the median rate for TTM <24 hours was 20% (IQR: 0%, 34%) and for achieved temperature <32°C was 18% (IQR: 0%, 39%), with marked variation across sites (median odds ratios of 1.44 [1.18–1.64] and 1.98 [1.62–2.31], respectively). Conclusions There has been a substantial decline in the utilization of TTM with significant variation in its real-world implementation. Further standardization of contemporary post-resuscitation practices, like TTM, is critical to ensure that their potential survival benefit is realized.

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