A framework for evaluating the appropriateness of clinical decision support alerts and responses

McCoy, Allison B.; Waitman, Lemuel R.; Lewis, Julia B.; Wright, Julie; Choma, David P.; Miller, Randolph A.; Peterson, Josh F.

doi:10.1136/amiajnl-2011-000185

Cited by 112 publications

(97 citation statements)

References 32 publications

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“…Study data were collected as part of a quality improvement program with Institutional Review Board approval to improve drug safety (16). Briefly, the program featured CPOEbased clinical decision support (17,18), prospective monitoring, and as necessary, intervention by a clinical pharmacist through an electronic surveillance tool. Data for this observational study were collected at discharge by an independent outcome assessor.…”

Section: Settingmentioning

confidence: 99%

Adverse Drug Events during AKI and Its Recovery

Cox

McCoy

Matheny

et al. 2013

Clinical Journal of the American Society of Nephrology

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SummaryBackground and objectives The impact of AKI on adverse drug events and therapeutic failures and the medication errors leading to these events have not been well described.Design, setting, participants, & measurements A single-center observational study of 396 hospitalized patients with a minimum 0.5 mg/dl change in serum creatinine who were prescribed a nephrotoxic or renally eliminated medication was conducted. The population was stratified into two groups by the direction of their initial serum creatinine change: AKI and AKI recovery. Adverse drug events, potential adverse drug events, therapeutic failures, and potential therapeutic failures for 148 drugs and 46 outcomes were retrospectively measured. Events were classified for preventability and severity by expert adjudication. Multivariable analysis identified medication classes predisposing AKI patients to adverse drug events.Results Forty-three percent of patients experienced a potential adverse drug event, adverse drug event, therapeutic failure, or potential therapeutic failure; 66% of study events were preventable. Failure to adjust for kidney function (63%) and use of nephrotoxic medications during AKI (28%) were the most common potential adverse drug events. Worsening AKI and hypotension were the most common preventable adverse drug events. Most adverse drug events were considered serious (63%) or life-threatening (31%), with one fatal adverse drug event. Among AKI patients, administration of angiotensin-converting enzyme inhibitors/angiotensin receptor blockers, antibiotics, and antithrombotics was most strongly associated with the development of an adverse drug event or potential adverse drug event.Conclusions Adverse drug events and potential therapeutic failures are common and frequently severe in patients with AKI exposed to nephrotoxic or renally eliminated medications.

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Section: Settingmentioning

confidence: 99%

Adverse Drug Events during AKI and Its Recovery

Cox

McCoy

Matheny

et al. 2013

Clinical Journal of the American Society of Nephrology

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“…In contrast to the results of a previous meta-analysis [4], this review found that decision support systems integrated into an electronic patient record or order entry interface were less likely to be effective than standalone systems [3]. A likely explanation for this finding is that these systems already had alerts and reminders in place at the time of the trial, and the users had developed "alert fatigue" --a habit of ignoring alerts and reminders brought about by repeated exposure [3], particularly to less relevant alerts [5]. A 2006 review found that 49% to 96% of alerts integrated into computerized order entry systems were ignored [6].…”

Section: Introductionmentioning

confidence: 82%

Development of Computerized Clinical Decision Support to Assist in Detecting and Preventing Delirium in the Hospital Setting

Medlock

Lagaay

Eslami

et al. 2014

2014 IEEE International Conference on Healthcare Informatics

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Delirium is an acute confusional state commonly affecting hospitalized older patients. As a part of the Improving Care of Vulnerable Elders (ICOVE) project, interventions were designed to improve delirium screening and reduce use of strong anticholinergic medications while avoiding contributing to alert fatigue. Methods: Baseline compliance was assessed for each step in the workflow. The intervention was designed in cooperation with the clinicians who are responsible for those steps and built using the integrated decision support facilities of the electronic patient record system. Compliance after the intervention is assessed using the same computerized measures used to determine the baseline and using statistical process control charts. Results: Baseline compliance for delirium screening was 62.3%. Baseline compliance for avoiding strong anticholinergics was 84.3%, but varied from 17.2% to 97.3% for different therapeutic classes. Clinicians asked for a column added to a patient summary table to indicate whether delirium screening had been performed, and a non-interruptive onscreen alert for strong anticholinergic medications. However, the prescribing alert could only be implemented as a modal dialog alert or a passive alert accessed through clicking a tab in the patient record. We implemented the modal dialog alert for orders and the passive alert for active medications. Conclusions: We were able to perform computerized assessment of delirium screening and avoidance of strong anticholinergic medications, although both rules contained ambiguous terms which needed to be defined for the intervention. Assessment of multiple outcomes proved useful both for assessing the quality of care and for identifying where additional support was needed. Assessing the specificity of inferences about data not recorded in structured fields also revealed areas for improvement that would otherwise be missed. Additional functionality for flexibility in decision support in electronic patient record systems may be needed to combat alert fatigue, although this must be weighed against the need to maintain a consistent user experience.

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“…To do so might require a more in-depth assessment, possibly including medical chart reviews. McCoy et al 9 published a framework for evaluating alert appropriateness.…”

Section: Original Research and Contributionsmentioning

confidence: 99%