Understanding handling of drug safety alerts: a simulation study.
OBJECTIVE
To study correctness of drug safety alert handling and error type in a computerized physician order entry (CPOE) system in a simulated work environment.


METHODS
Disguised observation study of 18 physicians (12 from internal medicine and 6 from surgery) entering 35 orders of predefined patient cases with 13 different drug safety alerts in a CPOE. Structured interviews about how the generated drug safety alerts were handled in the simulation test and resemblance of the test to the normal work environment. Handling and reasons for this were scored for correctness and error type.


RESULTS
Thirty percent of alerts were handled incorrectly, because the action itself and/or the reason for the handling were incorrect. Sixty-three percent of the errors were categorized as rule based and residents in surgery used incorrect justifications twice as often as residents in internal medicine. They often referred to monitoring of incorrect substances or parameters. One alert presented as a second alert in one screen was unconsciously overridden several times. One quarter of residents showed signs of alert fatigue.


CONCLUSIONS
Although alerts were mainly handled correctly, underlying rules and reasoning were often incorrect, thereby threatening patient safety. This study gave an insight into the factors playing a role in incorrect drug safety alert handling that should be studied in more detail. The results suggest that better training, improved concise alert texts, and increased specificity might help. Furthermore, the safety of the predefined override reason 'will monitor' and double alert presentation in one screen is questioned.
van der Sijs
Heleen
H
Department of Hospital Pharmacy, Erasmus University Medical Center, 3000 CA Rotterdam, The Netherlands. i.vandersijs@erasmusmc.nl
van Gelder
Teun
T
Vulto
Arnold
A
Berg
Marc
M
Aarts
Jos
J
D001291:Attitude of Health Personnel; D003198:Computer Simulation; D020000:Decision Support Systems, Clinical; D004347:Drug Interactions; D062787:Drug Overdose / Q000517:prevention & control; D011307:Drug Prescriptions; D004360:Drug Therapy, Computer-Assisted; D064420:Drug-Related Side Effects and Adverse Reactions; D006801:Humans; D050316:Medical Order Entry Systems; D008508:Medication Errors / Q000517:prevention & control*; D017010:Reminder Systems / Q000706:statistics & numerical data*