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Study: Improve drug warning alerts to reduce medication errors

Frankly, how much good is a computerized drug warning alert doing if drug prescribers and other hospital personnel seeing an alert simply override it more than 95 percent of the time?

That is a question that is being asked a lot in the wake of a study by researchers of Johns Hopkins Bayview Medical Center in Baltimore. The research team examined how personnel at a 410-bed academic medical center interacted with a computerized provider order entry (CPOE) system over a recent one-year period.

The bottom line: Mostly, they just ignored it, which is a reaction fundamentally at odds with what is hoped for by hospital administrators, who see CPOE systems as strong safeguards against medication errors.

What is the problem? Put another way, wherein lies the primary disincentive with working with the warning system to guard against patients' allergic reactions, bad interactions with other medications that a patient is taking, duplication error and other adverse events?

The researchers cite "alert fatigue," that is, the simple fact that those ordering prescriptions get burned out by being consistently confronted by an electronic system that many of them say is difficult and frustrating to work with.

One problem with the system that the Johns Hopkins team scrutinized is that, following a drug order, every conceivable warning pops up on the same screen in undifferentiated -- in fact, in identical -- size and font. The person looking at the screen has no indication that one potentially adverse outcome might be any more common or dire than another.

Instances of medical error and harm will not be reduced, the researchers state, without revision of CPOE systems "to more clearly differentiate between types of warnings and, in particular, to distinguish the warnings that are most likely to have severe consequences."

Source: Medpage Today, "Drug warning alerts largely ignored," Nancy Walsh, April 6, 2012

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