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Prospective evaluation of medication-related clinical decision support over-rides in the intensive care unit
  1. Adrian Wong1,
  2. Mary G Amato1,2,
  3. Diane L Seger3,
  4. Christine Rehr1,
  5. Adam Wright4,5,
  6. Sarah P Slight6,7,
  7. Patrick E Beeler8,
  8. E. John Orav9,
  9. David W Bates1
  1. 1 Division of General Internal Medicine and Primary Care, Brigham and Women’s Hospital, Boston, Massachusetts, USA
  2. 2 Department of Pharmacy and Therapeutics, MCPHS University, Boston, Massachusetts, USA
  3. 3 Clinical Quality Analysis, Partners Healthcare, Somerville, Massachusetts, USA
  4. 4 Department of Medicine, Brigham and Women’s Hospital, Boston, Massachusetts, USA
  5. 5 Department of Medicine, Harvard Medical School, Boston, Massachusetts, USA
  6. 6 Division of General Internal Medicine, The Center for Patient Safety Research and Practice, Brigham and Women’s Hospital, Boston, Massachusetts, USA
  7. 7 School of Pharmacy, Newcastle University, Newcastle upon Tyne, UK
  8. 8 Research Center for Medical Informatics, University Hospital Zurich, Zurich, Switzerland
  9. 9 Department of Biostatistics, Harvard School of Public Health, Boston, Massachusetts, USA
  1. Correspondence to Adrian Wong, Division of General Internal Medicine and Primary Care, Brigham and Women’s Hospital, Boston, MA 02115, USA; awong22{at}


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.

  • adverse drug event
  • clinical decision support
  • critical care
  • informatics
  • patient safety
  • quality of care
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  • Funding This study was funded by CRICO.

  • Competing interests DWB reported receiving equity from Intensix, which makes software to support clinical decision-making in intensive care; being named as coinventor on Patent Number 6029138 held by Brigham and Women’s Hospital on the use of decision support software for medical management, licensed to the Medicalis, and holding a minority equity position in Medicalis, which develops web-based decision support for radiology test ordering; consulting for Early Sense, which makes patient safety monitoring systems; receiving equity and cash compensation from QPID, a company focused on intelligence systems for electronic health records; receiving cash compensation from CDI (Negev), which is a not-for-profit incubator for health IT start-ups; receiving equity from Enelgy, which makes software to support evidence-based clinical decisions, from Ethosmart, which makes software to help patients with chronic diseases, and from MDClone, which takes clinical data and produces deidentified versions of it. The remaining authors have disclosed that they do not have any conflicts of interest.

  • Ethics approval Partners Institutional Review Board.

  • Provenance and peer review Not commissioned; externally peer reviewed.

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