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MDs Override Prescribing Alarms, Safety Value Persists


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MDs Override Prescribing Alarms, Safety Value Persists

By Tom A. Augello, CRICO

Related to: Ambulatory, Clinical Guidelines, Communication, Primary Care, Medication, Nursing, Obstetrics, Other Specialties

Some physicians still change behavior, even though they override 90 percent of alerts.

Guest Commentator

  • Saul Weingart, MD, PhD; Dana Farber Cancer Institute; Boston, MA


Medical facilities continue to feel pressure to incorporate electronic information tools to improve efficiency and reduce risks in clinical processes. To help prevent drug errors, for example, electronic prescribing is increasingly available, even in ambulatory care settings.

The federal government is providing incentives to providers to begin electronic prescribing in ambulatory care, where most prescriptions are written. Manufacturers of prescribing systems have sought to meet market demand to add software that goes beyond just automating a process—to incorporate intelligence that actually helps prescribers make better decisions.

This can mean an audio alert when a clinician attempts to prescribe an unconventional dose or a combination of drugs that is usually and widely contraindicated. When confronted with a noisy bell or unpleasant alarm, a prescriber can usually override these alerts.

Dr. Saul Weingart is Vice President of Quality Improvement and Patient Safety at Dana Farber Cancer Institute in Boston. Dr. Weingart recently co-authored a study in the Archives of Internal Medicine that looked at the rate at which clinicians overrode alarms that go off when using electronic prescribing.

"There is a widespread perception among clinicians that alerts occur too much. There is this concept of alert fatigue. There is this concept of alert overload. The idea is that when you turn on these electronic systems they bombard the clinician with information that may not be clinically useful or relevant and that rather than doing good, they are actually intruding on clinical care and getting in the way of efficient practice."

Dr. Weingart's research showed that physicians overrode the alerts nine out of 10 times. But Dr. Weingart says that's not the end of the story.

"The question that that begs is if docs override 90% of the alerts and accept only 9% or 10%, are we getting any benefit from that. In other words, what is the cost utilization and patient safety benefit of a relatively small number of cases where the docs change their perspective? So we have done some work on that and we have tried to model that…. and what we found is that in fact there is a patient safety benefit, that we do prevent injuries, that we do reduce utilization and in turn cost, principally from hospitalizations."

The question is whether that benefit is worth the cost, both in dollars and in physician time and mental distraction. Dr. Weingart's team is also looking at whether medical professionals who reject a prescribing alert do something differently to improve safety as a result, after they override the alarm.

"So, for example, if I get an alert and it tells me there is an interaction between two drugs, but both of them are needed—for example, a blood thinner and an antibiotic—then I might still go ahead and prescribe the medications because they are needed and at the same time arrange for the patient to come back a little earlier for follow-up or arrange for early blood tests or provide some counseling of some kind or another. Our preliminary research suggests that in fact ….those alerts are triggering actions by clinicians that is above and beyond what would be expected from the override rates themselves."

Dr. Weingart doesn't want doctors and manufacturers of electronic prescribing devices to throw the baby out with the bathwater. Given the existence of some patient safety and utilization benefit, an effort to make alerts work for doctors is worthwhile. Especially considering the risks that lurk behind the alarms.

"We know that the rate of adverse drug events in ambulatory care is about one in four. That means about one in four patients over the course of three months who receives a prescription will have some symptom related to the medication. Not that many of them are serious, and a minority of them are preventable, but many of them are ameliorable, meaning that the severity and duration of the symptom could be reduced if something was done differently, if the doctor made a better decision or if the doctor acted on patient information or if the patient communicated the information."

Despite growing federal pressure, electronic prescribing is not widespread in ambulatory care. Massachusetts has one of the highest penetration rates, but it's well under 30 percent.

Organizations that have shown the most success in balancing the number of alerts and the benefits tend to be large academic hospitals and their affiliated ambulatory sites. Dr. Weingart says that Boston's Brigham and Women's Hospital, for example, was able to tweak its proprietary software systems to suppress some alerts and drive the override rate down to 70 percent or so. They did this by creating a tiered system of alarms, with only the most serious problems triggering an alert.

"Ultimately, what we would really like to do is to be able to tie these electronic alerts into more information that is in an electronic health record. So, for example, if a patient is on an aspirin and an ACE inhibitor, that will fire an alert because those drugs can both have an effect on the kidney. However, if you have heart failure or heart disease, those are two indicated drugs that you want to have together. In fact, it improves clinical outcomes if you have those drugs on board at the same time. So if we could design an alert system that would suppress alerts when those drugs are used in combination in patients who have on their problem list heart failure, then we would be much further along."

January 1, 2009
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