Unintended effects of a computerized physician order entry nearly hard-stop alert to prevent a drug interaction: a randomized controlled trial.
BACKGROUND
The effectiveness of computerized physician order entry (CPOE) systems has been modest, largely because clinicians frequently override electronic alerts.


METHODS
To evaluate the effectiveness of a nearly "hard stop" CPOE prescribing alert intended to reduce concomitant orders for warfarin and trimethoprim-sulfamethoxazole, a randomized clinical trial was conducted at 2 academic medical centers in Philadelphia, Pennsylvania. A total of 1981 clinicians were assigned to either an intervention group receiving a nearly hard stop alert or a control group receiving the standard practice. The study duration was August 9, 2006, through February 13, 2007.


RESULTS
The proportion of desired responses (ie, not reordering the alert-triggering drug within 10 minutes of firing) was 57.2% (111 of 194 hard stop alerts) in the intervention group and 13.5% (20 of 148) in the control group (adjusted odds ratio, 0.12; 95% confidence interval, 0.045-0.33). However, the study was terminated early because of 4 unintended consequences identified among patients in the intervention group: a delay of treatment with trimethoprim-sulfamethoxazole in 2 patients and a delay of treatment with warfarin in another 2 patients.


CONCLUSIONS
An electronic hard stop alert as part of an inpatient CPOE system seemed to be extremely effective in changing prescribing. However, this intervention precipitated clinically important treatment delays in 4 patients who needed immediate drug therapy. These results illustrate the importance of formal evaluation and monitoring for unintended consequences of programmatic interventions intended to improve prescribing habits.


BACKGROUND
clinicaltrials.gov Identifier: NCT00870298.
Strom
Brian L
BL
Center for Clinical Epidemiology and Biostatistics, University of Pennsylvania School of Medicine, Philadelphia, PA 19104-6021, USA. bstrom@exchange.upenn.edu
Schinnar
Rita
R
Aberra
Faten
F
Bilker
Warren
W
Hennessy
Sean
S
Leonard
Charles E
CE
Pifer
Eric
E
D000890:Anti-Infective Agents / Q000008:administration & dosage / Q000009:adverse effects; D000925:Anticoagulants / Q000008:administration & dosage / Q000009:adverse effects; D003658:Decision Making, Computer-Assisted; D020000:Decision Support Systems, Clinical; D004347:Drug Interactions; D011307:Drug Prescriptions / Q000592:standards*; D004360:Drug Therapy, Computer-Assisted / Q000592:standards*; D055695:Electronic Prescribing; D006470:Hemorrhage / Q000139:chemically induced / Q000517:prevention & control; D006801:Humans; D050316:Medical Order Entry Systems; D008508:Medication Errors / Q000517:prevention & control*; D008510:Medication Systems, Hospital / Q000639:trends; D016017:Odds Ratio; D015143:Philadelphia; D017010:Reminder Systems; D013997:Time Factors; D015662:Trimethoprim, Sulfamethoxazole Drug Combination / Q000008:administration & dosage / Q000009:adverse effects; D014859:Warfarin / Q000008:administration & dosage / Q000009:adverse effects
D000890:Anti-Infective Agents; D000925:Anticoagulants; D014859:Warfarin; D015662:Trimethoprim, Sulfamethoxazole Drug Combination