Patient Safety Considerations with Medication Errors
Despite decades of research and integration, more work needs to be done to improve medication management within the current EHRs.
Summary
Medication error rates range from 5-20%
- 1 in every 10 deaths in the U.S. is attributable to an adverse drug event
Efforts to decrease medication errors with clinical decision support tools within electronic health records have produced minimal results
Most medication alerts (50 - 90% inpatients; 33 – 90% outpatients) are overridden
Ideal medication error prevention strategies are presented to drive a culture of patient safety
Background
With the recent uptake of electronic health records (EHR), medication based clinical decision support (CDS) and subsequent alerts have become a revived focus within health informatics and health services research. CDS for medication management include dose range checks, appropriate route checks, contraindications, drug-drug interactions and drug-disease interactions. Despite these components within EHRs, we have failed to improve patient safety due to medication errors.
Several factors contribute to the poor results.
A large number of alerts leading to “alert fatigue”. This high alert volume maybe due to inconsistent or poorly specified descriptions of patient problems and disease terminology emanating from EHRs.
Neglected maintenance within the EHR. As patient problems are resolved but not removed, alerts may continue to be triggered which are now irrelevant.
Minimal or inconsistent descriptions within alert warnings contributing to poor usability.
Review
Medication errors and adverse drug events occur during prescribing, dispensing or administration. Therefore, the ideal culture of patient safety should incorporate multiple preventative strategies at all phases of the medication use process.
Most medication safety CDS have focused on:
•allergy notifications;
• drug-drug interactions;
• conversion from high cost to lower cost efficacious agents;
• drug-disease interactions.
Typically, these CDS programs are results of table look up and present 3 levels of alerts to the end user.
Hard Stop or Contraindicated: Hard stops prevent the user from proceeding any further. These are rarely used in practice as they may prevent receiving potentially life-saving treatment in a timely manner.
Severe Warning: Provides the option to override the alert and typically requires the user to provide a reason for the override.
Moderate Warning or Informational only: May or may not require any action by the user.
Collecting override data is important for several reasons:
• Documentation of provider’s awareness of potential harm
• Attempt to influence behavior
• Assess data to improve knowledge base and notification system.
Although there is wide variability reported, data with over 3 million drug-drug interaction alerts show 2.8 million were overridden (91%), along with 2 million (71%) overrides with a reason. With 12 categories of override reasons, the top 3 accounted for 78% consisting of:
Will monitor or take precautions
Not clinically significant
Benefits outweigh risks
To improve the usability of medication alerts, the following characteristics should be incorporated:
Instead of simply listing the drug pair names and the concern (i.e. significant risk of increased INR with warfarin and trimethoprim/sulfamethoxazole), add patient context of relevant data (i.e. patient INR from 3 hours ago = 2.3)
Provide user the ability to take specific actions to monitor or decrease risk directly from notification (i.e. order additional INR monitoring or decrease warfarin dose)
Allow user to cancel and change the new medication contributing to the problem.
Provide a small number of tailored, accurate override reasons and/or free text for rationale.
Communicate documentation of problem and reasoning/changes to other healthcare provider team members.
Conclusions
Despite decades of research and integration, more work needs to be done to improve medication management within the current EHRs
To decrease alert fatigue, notifications need to be more specific to the drug pair, include patient contextual actionable information, and provide ability to intervene directly from notification
Redesign includes improvement in the quality of override reasons, their collection, reporting and review.