Understanding handling of drug safety alerts: a simulation study

Area of Science:

• Medical Informatics
• Patient Safety
• Clinical Decision Support

Background:

• Computerized physician order entry (CPOE) systems aim to enhance patient safety by providing drug safety alerts.
• However, the effectiveness of these alerts depends on correct physician handling and understanding.

Purpose of the Study:

• To evaluate the accuracy of drug safety alert handling and identify error types within a CPOE system.
• To assess physician behavior and reasoning when responding to drug safety alerts in a simulated clinical setting.

Main Methods:

• A disguised observation study involving 18 physicians (internal medicine and surgery) entering orders with predefined drug safety alerts.
• Structured interviews were conducted to gather insights into alert handling and the simulation's realism.
• Physician actions and justifications for handling alerts were scored for correctness and error type.

Main Results:

• Thirty percent of drug safety alerts were handled incorrectly, with errors in both action and reasoning.
• Rule-based errors constituted 63% of incorrect handling, with surgical residents providing incorrect justifications more frequently than internal medicine residents.
• Alert fatigue was observed in one quarter of residents, and specific alert presentations (e.g., double alerts) led to unconscious overrides.

Conclusions:

• Despite generally correct alert actions, flawed underlying reasoning poses a significant threat to patient safety.
• Factors contributing to incorrect alert handling require further investigation.
• Recommendations include enhanced training, clearer alert messaging, and improved alert specificity, with a call to re-evaluate the safety of certain override reasons and alert presentations.