title: The effect of requesting a reason for non-adherence to a guideline in a long running automated reminder system for PONV prophylaxis.
abstract: Automated reminders are employed frequently to improve guideline adherence, but limitations of automated reminders are becoming more apparent. We studied the reasons for non-adherence in the setting of automated reminders to test the hypothesis that a separate request for a reason in itself may further improve guideline adherence.
  
  
  
  In a previously implemented automated reminder system on prophylaxis for postoperative nausea and vomiting (PONV), we included additional automated reminders requesting a reason for non-adherence. We recorded these reasons in the pre-operative screening clinic, the OR and the PACU. We compared adherence to our PONV guideline in two study groups with a historical control group.
  
  
  
  Guideline adherence on prescribing and administering PONV prophylaxis (dexamethasone and granisetron) all improved compared to the historical control group (89 vs. 82% (p< 0.0001), 96 vs 95% (not significant) and 90 vs 82% (p<0.0001)) while decreasing unwarranted prescription for PONV prophylaxis (10 vs. 13 %). In the pre-operative screening clinic, the main reason for not prescribing PONV prophylaxis was disagreement with the risk estimate by the decision support system. In the OR/PACU, the main reasons for not administering PONV prophylaxis were: 'unintended non-adherence' and 'failure to document'.
  
  
  
  In this study requesting a reason for non-adherence is associated with improved guideline adherence. The effect seems to depend on the underlying reason for non-adherence. It also illustrates the importance of human factors principles in the design of decision support. Some reasons for non-adherence may not be influenced by automated reminders.
authors.affiliation: Fabian O. Kooij, Academic Medical Centre, University of Amsterdam, Department of anaesthesia, PO Box 22660, 1100 DD Amsterdam, Phone: +31 20 566 2533, Fax: +31 20 697 9441, Email: F.O.Kooij@amc.nl.
authors.forename: Fabian O
authors.initials: FO
authors.lastname: Kooij
authors.forename: Toni
authors.initials: T
authors.lastname: Klok
authors.forename: Benedikt
authors.initials: B
authors.lastname: Preckel
authors.forename: Markus W
authors.initials: MW
authors.lastname: Hollmann
authors.forename: Jasper E
authors.initials: JE
authors.lastname: Kal
mesh_terms: D001331:Automation; D020000:Decision Support Systems, Clinical; D004282:Documentation; D005260:Female; D019983:Guideline Adherence / Q000706:statistics & numerical data*; D006801:Humans; D008297:Male; D020250:Postoperative Nausea and Vomiting / Q000517:prevention & control*; D017010:Reminder Systems / Q000706:statistics & numerical data*
keywords: Automated reminders; PONV; decision support