title: Evaluation of medication-related clinical decision support alert overrides in the intensive care unit.
abstract: Medication-related clinical decision support (CDS) has been identified as a method to improve patient outcomes but is historically frequently overridden and may be inappropriately so. Patients in the intensive care unit (ICU) are at a higher risk of harm from adverse drug events (ADEs) and these overrides may increase patient harm. The objective of this study is to determine appropriateness of overridden medication-related CDS overrides in the ICU.
  
  
  
  We evaluated overridden medication-related alerts of four alert categories from January 2009 to December 2011. The primary outcome was the appropriateness of a random sample of overrides based on predetermined criteria. Secondary outcomes included the incidence of adverse drug events (ADEs) that resulted from the overridden alert.
  
  
  
  A total of 47,449 overridden alerts were included for evaluation. The appropriateness rate for overridden alerts varied by alert category (allergy: 94%, drug-drug interaction: 84%, geriatric: 57%, renal: 27%). A total of seven actual ADEs were identified in the random sample and where the medication(s) was administered (n=366), with an increased risk of ADEs associated with inappropriately overridden alerts (p=0.0078).
  
  
  
  The appropriateness of medication-related clinical decision support overrides in the ICU varied substantially by the type of alert. Inappropriately overridden alerts were associated with an increased risk of ADEs compared to appropriately overridden alerts.
authors.affiliation: The Center for Patient Safety Research and Practice, Division of General Internal Medicine and Primary Care, Brigham and Women's Hospital, Boston, MA, USA; MCPHS University, Boston, MA, USA.
authors.forename: Adrian
authors.initials: A
authors.lastname: Wong
authors.affiliation: The Center for Patient Safety Research and Practice, Division of General Internal Medicine and Primary Care, Brigham and Women's Hospital, Boston, MA, USA; MCPHS University, Boston, MA, USA.
authors.forename: Mary G
authors.initials: MG
authors.lastname: Amato
authors.affiliation: The Center for Patient Safety Research and Practice, Division of General Internal Medicine and Primary Care, Brigham and Women's Hospital, Boston, MA, USA; Partners HealthCare, Wellesley, Boston, MA, USA.
authors.forename: Diane L
authors.initials: DL
authors.lastname: Seger
authors.affiliation: The Center for Patient Safety Research and Practice, Division of General Internal Medicine and Primary Care, Brigham and Women's Hospital, Boston, MA, USA; School of Medicine, Pharmacy and Health, The University of Durham, Stockton on Tees, Durham, UK; Newcastle University, Newcastle-upon-Tyne, UK.
authors.forename: Sarah P
authors.initials: SP
authors.lastname: Slight
authors.affiliation: The Center for Patient Safety Research and Practice, Division of General Internal Medicine and Primary Care, Brigham and Women's Hospital, Boston, MA, USA; Research Center for Medical Informatics, University Hospital, Zurich, Switzerland; Harvard Medical School, Boston, MA, USA.
authors.forename: Patrick E
authors.initials: PE
authors.lastname: Beeler
authors.affiliation: The Center for Patient Safety Research and Practice, Division of General Internal Medicine and Primary Care, Brigham and Women's Hospital, Boston, MA, USA; Harvard Medical School, Boston, MA, USA.
authors.forename: Patricia C
authors.initials: PC
authors.lastname: Dykes
authors.affiliation: The Center for Patient Safety Research and Practice, Division of General Internal Medicine and Primary Care, Brigham and Women's Hospital, Boston, MA, USA; Partners HealthCare, Wellesley, Boston, MA, USA.
authors.forename: Julie M
authors.initials: JM
authors.lastname: Fiskio
authors.affiliation: The Center for Patient Safety Research and Practice, Division of General Internal Medicine and Primary Care, Brigham and Women's Hospital, Boston, MA, USA; Partners HealthCare, Wellesley, Boston, MA, USA.
authors.forename: Elizabeth R
authors.initials: ER
authors.lastname: Silvers
authors.affiliation: Department of Biostatistics, Harvard T.H. Chan School of Public Health, Boston, MA, USA.
authors.forename: E John
authors.initials: EJ
authors.lastname: Orav
authors.affiliation: The Center for Patient Safety Research and Practice, Division of General Internal Medicine and Primary Care, Brigham and Women's Hospital, Boston, MA, USA; MCPHS University, Boston, MA, USA.
authors.forename: Tewodros
authors.initials: T
authors.lastname: Eguale
authors.affiliation: The Center for Patient Safety Research and Practice, Division of General Internal Medicine and Primary Care, Brigham and Women's Hospital, Boston, MA, USA; Harvard Medical School, Boston, MA, USA. Electronic address: dbates@partners.org.
authors.forename: David W
authors.initials: DW
authors.lastname: Bates
mesh_terms: D000368:Aged; D003422:Critical Care / Q000706:statistics & numerical data*; D020000:Decision Support Systems, Clinical; D064420:Drug-Related Side Effects and Adverse Reactions / Q000209:etiology*; D005260:Female; D006801:Humans; D007362:Intensive Care Units / Q000706:statistics & numerical data; D008297:Male; D050316:Medical Order Entry Systems / Q000706:statistics & numerical data*; D008508:Medication Errors / Q000706:statistics & numerical data; D008875:Middle Aged
keywords: Adverse drug event; Clinical decision support; Critical care; Patient safety; Quality of care