Heed this warning! Don't miss important computer alerts
From the February 8, 2007 issue
Problem: Although pharmacists typically enter prescriptions and orders into the pharmacy computer, in some settings, specially trained pharmacy technicians or pharmacy interns perform this function. In these circumstances, a pharmacist later verifies that the order has been entered as prescribed at the same time he or she is assuring the appropriateness of the medication and verifying that the proper drug and dose has been prepared. The checking process is typically accomplished by comparing the order, pharmacy label, and the final product. As long as the original prescription or order is included in the checking process, this may seem to be a perfectly acceptable way to verify technician/ pharmacy intern order entry and preparation of medications. However, one glaring safety concern still exists with this process: the checking pharmacists may not know about alerts that were displayed during the order entry process and bypassed. As long as the order was entered as prescribed, the pharmacist may not be in a position to view computer alerts about a drug interaction, allergy, duplicate therapy, excessive or subtherapeutic dose, or other contraindications.
While bypassing alerts is often clinically appropriate, sometimes important warnings are inappropriately overridden. Bypassing alerts appears to be a rather common practice, especially if the significance of the alert is not valued by the viewer of the information. The alert systems used during order entry are often quite sensitive so users do not miss any critical information. This sensitivity comes at a cost: frequent ‘false’ alarms—or warnings that may not be clinically significant. Pharmacists can usually cite many examples of these false alarms. Besides being a nuisance, frequent false alarms can lead to alert fatigue and complacency—or the ‘cry wolf’ syndrome.(1) Individual quirks in some pharmacy systems also contribute to missed alerts—conditions that should have given rise to an alert but did not. Thus, general annoyance and mistrust in the alert system could be one reason why it may seem perfectly acceptable to not worry about the alerts that technicians/ pharmacy interns may bypass.
Safe Practice Recommendations: The problems described above are twofold: false alarms with pharmacy alert systems and the pharmacist’s inability to view and assess alerts that may have been bypassed during order entry. While there are no silver bullets that can solve either problem quickly and effectively, a few suggestions are offered below to improve upon our valuable but imperfect alert systems.
Reduce sensitivity of alert system. The most direct way to curtail false alarms is to reduce the sensitivity of the alert system.(1) For example, many pharmacy systems allow users to choose the level of drug-drug interaction alerts (e.g., level 1-3) that will appear during order entry. While the existing level system is not perfect, it offers some relief from false, low significance alarms. However, keep in mind that reduced alert sensitivity leads to tradeoffs between false alerts and missed alerts.
Identify priority alerts. Another option is to identify conditions that signal the most serious potential adverse drug events, and use the list to limit and customize computer alerts. For example, there is a relatively small, finite group of drug interactions that are clinically important from a pharmacodynamic or pharmacokinetic standpoint. Several health professionals have published lists of these priority conditions, which can be used to target customized drug-drug interaction alerts, or to serve as a resource for pharmacists who are checking orders.(2,3) (See Table 1 in the PDF version of the newsletter for examples.) You can also identify priority alerts by reviewing previous pharmacy interventions regarding drug-drug interactions, allergies, duplicate therapy, and so on, to learn the conditions that truly warranted a call to the prescriber and changes in drug therapy. Likewise, encourage clinicians to report encounters of invalid warnings so they can be altered or removed from the pharmacy computer system. Once high-priority alerts have been identified, it should be impossible for order entry technicians/pharmacy interns to bypass these. Instead, these orders should remain in a queue for release by a pharmacist after viewing and responding to the associated problem. If a pharmacist eventually bypasses a high-priority alert, require documentation of the reason so it can be used for improvement activities.
Print a daily report of bypassed alerts. Most computer systems will allow a report of bypassed alerts to be printed daily for a pharmacist to review. This may be during the nighttime hours in some locations, or there may be other recognized periods when workload is lower, staffing is better, or someone is scheduled for this purpose. This is much more achievable if reports for bypassed priority alerts are created and reviewed. Otherwise, the length of the report may prohibit review and follow up. The exact process for follow up with problematic orders would also need to be described, especially if the review occurs at night. While retrospective review of bypassed alerts is not optimal, many drug-drug interactions, even some severe ones, will not harm patients until at least a few days after concurrent administration, so there is often time to take action before harm occurs. The same may not be true for some duplicate therapy, allergies, and dosing errors, but harm may be mitigated if the problem is discovered quickly.
Alerts on labels. Some order entry systems have the ability to print out any significant alerts on a label along with the other product labels that are produced. This way, the pharmacist will be able to view the bypassed alerts when checking the final product before dispensing. However, unless the labels with alerts are available in real time, the logistics of this option are impractical for inpatient settings, particularly if most medications are dispensed via automated dispensing cabinets.
References: 1) Wogalter MS ed. Handbook of Warnings. Lawrence Erlbaum Associates: Mahwah, NJ; 2006. 2) Splete H. Medical history holds clues to drug interactions. Internal Med News, 2005;38(22):42. 3) Hansten PD, Horn JR. The top 100 drug interactions: a guide to patient management, 2006 edition. American College of Clinical Pharmacy: Boston, MA; 2006.