Opioid duplicate therapy alert optimization through use of custom PRN indications

Opioid analgesics are commonly prescribed for inpatient pain control. Duplicate therapy alerts exist to prevent adverse effects and maintain compliance with The Joint Commission; however, high alert volume and low clinical relevance contribute to alert fatigue and desensitization. Leveraging order sets, duplicate therapy allowances, and protocols can optimize duplicate therapy alerts, but further opportunity for improvement exists.

This retrospective study evaluated a process to reduce alert volume by optimizing immediate-release (IR) opioid duplicate therapy alerts in a large community health system. The study included alerts attributed to at least 2 PRN (as-needed) opioid orders for adult inpatients. In phase I, the health system implemented clinical decision support logic to silence alerts for different PRN indications. In phase II, the pharmacy department created new discrete PRN indication checkboxes within electronic opioid orders, and in phase III order sets were revised to support the new indications. In phase IV, extraneous medications were removed from the alert. The primary outcome was the number of duplicate therapy alerts per 1,000 PRN opioid orders. The pharmacy department assessed alert and order volumes in separate 1-week periods.

Before intervention, there were 1,382 duplicate therapy alerts per 1,000 PRN opioid orders. After intervention, 378 duplicate therapy alerts fired per 1,000 PRN opioid orders, representing a 72.6% decrease from baseline. In both groups, the majority of IR opioid duplicate therapy alerts occurred in surgical settings and were overridden 70% of the time.

Efforts to optimize opioid duplicate therapy alerts through clinical decision support tools, discrete PRN indication boxes, and order set review resulted in decreased alert burden associated with PRN opioid orders.