Clinically Inconsequential Alerts: The Characteristics of Opioid Drug Alerts and Their Utility in Preventing Adverse Drug Events in the Emergency Department

Abstract

Study objective We examine the characteristics of clinical decision support alerts triggered when opioids are prescribed, including alert type, override rates, adverse drug events associated with opioids, and preventable adverse drug events. Methods This was a retrospective chart review study assessing adverse drug event occurrences for emergency department (ED) visits in a large urban academic medical center using a commercial electronic health record system with clinical decision support. Participants include those aged 18 to 89 years who arrived to the ED every fifth day between September 2012 and January 2013. The main outcome was characteristics of opioid drug alerts, including alert type, override rates, opioid-related adverse drug events, and adverse drug event preventability by clinical decision support. Results Opioid drug alerts were more likely to be overridden than nonopioid alerts (relative risk 1.35; 95% confidence interval [CI] 1.21 to 1.50). Opioid drug-allergy alerts were twice as likely to be overridden (relative risk 2.24; 95% CI 1.74 to 2.89). Opioid duplicate therapy alerts were 1.57 times as likely to be overridden (95% CI 1.30 to 1.89). Fourteen of 4,581 patients experienced an adverse drug event (0.31%; 95% CI 0.15% to 0.47%), and 8 were due to opioids (57.1%). None of the adverse drug events were preventable by clinical decision support. However, 46 alerts were accepted for 38 patients that averted a potential adverse drug event. Overall, 98.9% of opioid alerts did not result in an actual or averted adverse drug event, and 96.3% of opioid alerts were overridden. Conclusion Overridden opioid alerts did not result in adverse drug events. Clinical decision support successfully prevented adverse drug events at the expense of generating a large volume of inconsequential alerts. To prevent 1 adverse drug event, providers dealt with more than 123 unnecessary alerts. It is essential to refine clinical decision support alerting systems to eliminate inconsequential alerts to prevent alert fatigue and maintain patient safety.

Emergency Department Provider Perspectives on Benzodiazepine–Opioid Coprescribing: A Qualitative Study

“…When exploring receptiveness to various potential interventions to reduce the incidence of coprescribing, prescribers and pharmacists reported universal opposition to a computer alert intervention. This is consistent with the known literature on the high override rate of drug alerts . Additionally, participants were generally unaware of national‐ or hospital‐level guidelines on coprescribing despite the recent release of the CDC chronic opioid prescribing guidelines, suggesting that guidelines may not be an effective means to impact prescribing behavior.…”

The Association of EHR Drug Safety Alerts and Co-prescribing of Opioids and Benzodiazepines

“…However, other research finds that physicians frequently override clinical decision support alerts related to opioids, suggesting that clinicians may suffer from EHR alert fatigue. 4 One advantage of using EHR data is the ability to observe medication orders along with detailed diagnosis information recorded during the associated visit. However, our analysis has limitations.…”

Optimizing Clinical Decision Support in the Electronic Health Record

“…Conversely, there is peril associated with implementing CDSSs without proper education and feedback. Take for example, the evidence suggesting that adverse drug reaction alerts do little to change clinician-prescribing behavior, such as warnings about opioid prescriptions [29]. Consider as well the potentially deleterious effect of the number of "clicks" that EPs working in an EHR-enabled environment face each shift [30].…”