@article {Wong718, author = {Adrian Wong and Mary G Amato and Diane L Seger and Christine Rehr and Adam Wright and Sarah P Slight and Patrick E Beeler and E. John Orav and David W Bates}, title = {Prospective evaluation of medication-related clinical decision support over-rides in the intensive care unit}, volume = {27}, number = {9}, pages = {718--724}, year = {2018}, doi = {10.1136/bmjqs-2017-007531}, publisher = {BMJ Publishing Group Ltd}, abstract = {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{\textendash}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{\textquoteright}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.}, issn = {2044-5415}, URL = {https://qualitysafety.bmj.com/content/27/9/718}, eprint = {https://qualitysafety.bmj.com/content/27/9/718.full.pdf}, journal = {BMJ Quality \& Safety} }