前瞻性评估 ICU 中与药物相关的临床决策支持的Override 情况。

Prospective evaluation of medication-related clinical decision support over-rides in the intensive care unit.

机构信息

Division of General Internal Medicine and Primary Care, Brigham and Women's Hospital, Boston, Massachusetts, USA.

Department of Pharmacy and Therapeutics, MCPHS University, Boston, Massachusetts, USA.

出版信息

BMJ Qual Saf. 2018 Sep;27(9):718-724. doi: 10.1136/bmjqs-2017-007531. Epub 2018 Feb 9.

DOI:10.1136/bmjqs-2017-007531

PMID:29440481

Abstract

BACKGROUND

Clinical decision support (CDS) displayed in electronic health records has been found to reduce the incidence of medication errors and adverse drug events (ADE). Recent data suggested that medication-related CDS alerts were frequently over-ridden, often inappropriately. Patients in the intensive care unit (ICU) are at an increased risk of ADEs; however, limited data exist on the benefits of CDS in the ICU. This study aims to evaluate potential harm associated with medication-related CDS over-rides in the ICU.

METHODS

This was a prospective observational study of adults admitted to any of six ICUs between July 2016 and April 2017 at our institution. Patients with provider-overridden CDS for dose (orders for scheduled frequency and not pro re nata), drug allergy, drug-drug interaction, geriatric and renal alerts (contraindicated medications for renal function or renal dosing) were included. The primary outcome was the appropriateness of over-rides, which were evaluated by two independent reviewers. Secondary outcomes included incidence of ADEs following alert over-ride and risk of ADEs based on over-ride appropriateness.

RESULTS

A total of 2448 over-ridden alerts from 712 unique patient encounters met inclusion criteria. The overall appropriateness rate for over-rides was 81.6% and varied by alert type. More ADEs (potential and definite) were identified following inappropriate over-rides compared with appropriate over-rides (16.5 vs 2.74 per 100 over-ridden alerts, Fisher's exact test P<0.001). An adjusted logistic regression model showed that inappropriate over-rides were associated with an increased risk of ADEs (OR 6.14, 95% CI 4.63 to 7.71, P<0.001).

CONCLUSIONS

Approximately four of five identified CDS over-rides were appropriately over-ridden, with the rate varying by alert type. However, inappropriate over-rides were six times as likely to be associated with potential and definite ADEs, compared with appropriate over-rides. Further efforts should be targeted at improving the positive predictive value of CDS such as by suppressing alerts that are appropriately over-ridden.

摘要

背景

临床决策支持（CDS）在电子健康记录中的显示已被发现可降低药物错误和药物不良事件（ADE）的发生率。最近的数据表明，药物相关的 CDS 警报经常被覆盖，而且往往是不适当的。重症监护病房（ICU）的患者发生 ADE 的风险增加；然而，关于 ICU 中 CDS 的益处的数据有限。本研究旨在评估 ICU 中与药物相关的 CDS 覆盖所带来的潜在危害。

方法

这是一项前瞻性观察性研究，纳入了 2016 年 7 月至 2017 年 4 月期间我院六家 ICU 中收治的成年人患者。纳入了对 CDS 进行覆盖的患者，包括剂量相关的 CDS 覆盖（计划的频率而非按需给药）、药物过敏、药物相互作用、老年和肾功能警报（禁忌用于肾功能或肾功能剂量的药物）。主要结局是覆盖的适当性，由两名独立评审员进行评估。次要结局包括在警报覆盖后 ADE 的发生率以及基于覆盖适当性的 ADE 风险。

结果

共有 712 例患者发生的 2448 次警报覆盖符合纳入标准。覆盖的总体适当率为 81.6%，且按警报类型而有所不同。与适当覆盖相比，不适当覆盖后发现了更多的 ADE（潜在和确定）（每 100 次覆盖警报分别为 16.5 和 2.74，Fisher 精确检验 P<0.001）。调整后的逻辑回归模型显示，不适当覆盖与 ADE 风险增加相关（OR 6.14，95%CI 4.63 至 7.71，P<0.001）。