Department of Pharmacy Practice, MCPHS University, Boston, MA, USA.
The Center for Patient Safety Research and Practice, Brigham and Women's Hospital, Boston, MA, USA.
Drug Saf. 2019 Apr;42(4):573-579. doi: 10.1007/s40264-018-0756-x.
Medication-related clinical decision support (CDS) alerts have been shown to be effective at reducing adverse drug events (ADEs). However, these alerts are frequently overridden, with limited data linking these overrides to harm. Dose-range checking alerts are a type of CDS alert that could have a significant impact on morbidity and mortality, especially in the intensive care unit (ICU) setting.
We performed a single-center, prospective, observational study of adult ICUs from September 2016 to April 2017. Targeted overridden alerts were triggered when doses greater than or equal to 5% over the maximum dose were prescribed. The primary outcome was the appropriateness of the override, determined by two independent reviewers, using pre-specified criteria formulated by a multidisciplinary group. Overrides which resulted in medication administration were then evaluated for ADEs by chart review.
The override rate of high dose-range alerts in the ICU was 93.0% (total n = 1525) during the study period. A total of 1418 overridden alerts from 755 unique patients were evaluated for appropriateness (appropriateness rate 88.8%). The most common medication associated with high dose-range alerts was insulin regular infusion (n = 262, 18.5%). The rates of ADEs for the appropriately and inappropriately overridden alerts per 100 overridden alerts were 1.3 and 5.0, respectively (p < 0.001).
Overriding high dose-range CDS alerts was found to be common and often appropriate, suggesting that more intelligent dose checking is needed. Some alerts were clearly inappropriately presented to the provider. Inappropriate overrides were associated with an increased risk of ADEs, compared to appropriately overridden alerts.
药物相关的临床决策支持（CDS）警报已被证明可有效降低药物不良事件（ADE）的发生。然而，这些警报经常被忽视，仅有少量数据将这些忽视与伤害联系起来。剂量范围检查警报是一种 CDS 警报，它可能对发病率和死亡率产生重大影响，尤其是在重症监护病房（ICU）环境中。
我们进行了一项单中心、前瞻性、观察性研究，纳入了 2016 年 9 月至 2017 年 4 月期间的成人 ICU。当处方的剂量超过最大剂量的 5%时，就会触发目标性的过量警报。主要结局是由两名独立评审员根据一个多学科小组制定的预定义标准，使用预先指定的标准来确定干预的合理性。然后通过图表审查评估导致药物管理的干预是否会发生 ADE。
在研究期间，ICU 中高剂量范围警报的干预率为 93.0%（总 n=1525）。共有 755 名患者的 1418 次过量警报被评估干预的合理性（合理性率为 88.8%）。与高剂量范围警报相关的最常见药物是胰岛素常规输注（n=262，18.5%）。每 100 次过量干预的适当和不适当干预的 ADE 发生率分别为 1.3%和 5.0%（p<0.001）。
高剂量范围 CDS 警报的干预被发现很常见且通常是合理的，这表明需要更智能的剂量检查。一些警报显然是不合理地呈现给提供者的。与适当干预相比，不适当的干预与 ADE 风险增加相关。
