FUNDAMENTO Y CRITERIOS JURISPRUDENCIALES PARA LA

This study in a simulated work environment showed that physicians handled many drug safety alerts incorrectly at the RB level, using many different rules. Respondents often justified their overrides referring to monitoring serum levels or patient conditions, but the substances men- tioned or patient parameters were often incorrect. Four respondents said they would monitor renal function, diuresis or electrolytes when blood pressure monitoring was appropriate, oth- ers referred to tacrolimus serum level monitoring or clinical observation when ECG recording was indicated. In several CPOEs the override reason ‘patient being monitored’ can be selected from a dropdown box and pharmacists perceive this as useful for order verification [13-15]. Our findings suggest the reason ‘patient being monitored’ is insufficient to prevent error and should Table 3 Remarks made suggesting alert fatigue

There are so many drug-drug interactions that are irrelevant, that I am often inclined to rapidly click them away [resident in internal medicine ].

Those alerts, there are so many, they should be as limited as possible [resident in internal medicine].

You are completely overwhelmed by those (QT) alerts, so you are not setting your heart on it anymore [resident in internal medicine].

You get these overdose alerts really in and out of season [resident in surgery].

All those drug-drug interactions and all those things you get reported drive you mad. You get all those DDIs reported; you simply skip them. I only cancel orders in case of overdose alerts. If I have to consider every DDI, than I am busy with it, all day, and that is not my job. We do not think about whether it is a DDI or should be handled by us, that is not the issue [resident in surgery].

ideally be accompanied by clinical rules checking for correct serum levels, ECG recordings, and blood pressure measurements.

The high number of SB errors in handling the combination paroxetin-diclofenac can prob- ably be attributed to the presentation of two DDI alerts in one pop-up screen (Figure 1), as was mentioned by one of the physicians. Separate screens pop up for different alert types (i.e., overdoses, duplicate orders and DDIs) and generally only one alert is presented per screen. In the case of diclofenac generating two DDI alerts, the physician may overlook the second alert, thinking that the override button for the (first) alert has not worked properly, and thereby unin- tentionally override the second alert. Usability studies are necessary to find out whether double alert presentation indeed provokes unintended overrides and whether a different method of presentation can prevent them.

SB errors were observed less frequently than RB and KB errors, which is in line with the literature [6]. Generally SB behavior is frequently used, with a low error rate [6]. In this study, however, only 5% of cases were categorized as SB and the observed SB error rate was very high (80%). At first sight, these findings seem to deviate from normal alert handling, but it can be

Respond to alert and cancel new order Override alert and confirm new order Stop current order Current orders New medication order

Second drug interacting with diclofenac First drug interacting with diclofenac Alert recommendation

Figure 1 Drug-drug interaction alert

Example of alert screen presented to a physician ordering diclofenac (new order) when carvedilol and paroxetine (current orders) are already on the patient’s medication list. After overriding the first DDI carvedilol-diclofenac, a √ is placed before carvedilol and the alert text for paroxetine-diclofenac is presented in the same place as the former alert recommendation.

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questioned whether drug safety alerts can be performed adequately on a SB level. The alert has to be read and understood before the alert can be handled appropriately, and this requires RB or KB behavior. The SRK framework is generally used for error analysis in industrial environ- ments, where easily interpretable displays result in SB behavior. In this study, only overdose alerts are presented graphically with bars in red and green which are easily interpretable. All DDI and duplicate order alerts appear similar at first sight and it is necessary to read the drugs involved and/or the alert text. This would imply that SB behavior should be absent in alert handling for DDIs and duplicate orders and explains why a high error rate is observed if these alerts are handled at the SB level.

The percentage correctly handled drug safety alerts was 76% for both specialties, but this number only included correct overriding, adjustment or annulment, and did not include cor- rect monitoring, rules, or reasoning. The rules surgical residents used to justify their handling were incorrect twice as often as the rules used by residents in internal medicine. These mis- takes, accidentally resulting in correct handling in these simulated patient cases, could easily provoke incorrect handling and patient harm in other situations with the same alerts. Generally surgeons are less pharmacotherapy-minded than internists and therefore we expected less drug-related knowledge, more KB and less RB behavior. The percentages RB and KB behavior were comparable however (RB 71% and 70%; KB 26% and 25%), which suggests that both groups were about equally certain about their answers.