PLANTEAMIENTO GENERAL ACOTACIÓN
II. 1 RELACIÓN ENTRE FINES, OBJETIVOS Y CONCLUSIONES.
Alert fatigue was clearly present for several respondents from both specialties, but was absent in some physicians who were satisfied with the alerting function of the CPOE. Dependency on alert generation and alert recommendations could not be proven as none of the respondents admitted to relying fully on the alerting system. Those using the alert recommendations either intended to perform additional checks or did not mention whether they would check.
Error management
Error management aims at prevention, visible error notification, and mitigation of the effects of errors [16,17]. Errors committed on different cognitive levels require different interventions to prevent them [4,6]. KB behavior generally is very error prone and this type of behavior should be prevented and be replaced by RB behavior as much as possible. As drug treatment is very complex, prevention of KB behavior is impossible, although rules about how to handle unknown alerts might be helpful (e.g., read the alert text completely and carefully). Informative, clear alert texts might help physicians in KB decision making and would probably lower the error rate.
Rules used in RB behavior have been learned from textbooks, other persons or from previous experience and may be very strong if employed successfully in the past. RB errors are catego- rized as incorrect rules, incorrectly applied rules, and failures to apply best rules and may be
due to insufficient training. Education is proposed as a measure to counteract RB errors, but is time consuming [4].
Generally, SB errors are easily detected because the intended plan is correct, but in this study this was not the case. The SB ‘unintended override’ errors were almost invisible in Medicatie/ EVS
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version 2.30 (‘you do not get the warning again, and there is no button to get it back’) and therefore feedback about the erroneous action was absent. In a newer version of this CPOE (2.40), an override icon is present in the medication overview, which can be opened to view the drug(s) involved, and the complete alert text. This new feature improves error notification by prescribers and supervisors and might play a role in error reduction. It furthermore enables dedicated alert handling at a more suitable time, which seems to be useful as lack of time has been shown to be an important factor negatively affecting decision support acceptance [18].Reason’s model of accident causation applied to drug safety alerts in CPOE shows that active failures, such as ignoring and misinterpreting alerts and wrong selections, should be prevented by reducing or removing error-producing and latent conditions [1].
Ignoring
Several respondents admitted to clicking alerts away without reading them and one respon- dent could not recall handling of 4 different alerts. Suggested measures to prevent alerts from being ignored are improving specificity and directing time-dependent DDI alerts to other people in the workflow (nurses). Implementation of the sequence indications available in the Dutch drug database would improve specificity by reducing the high number of false-positive sequence-dependent DDIs (furosemide-captopril) [7].
Misinterpretation
Misinterpretation was rife, as shown by the high numbers of wrong or inapplicable rules and reasoning. Misinterpretation may be due to unclear alert texts or texts that are not read com- pletely. The interviews performed in this study suggest that both play a role. The recommended response to the alert, which is generally located low down in the alert text, was rarely men- tioned in the handling justifications. Respondents often referred to drug serum levels that were inappropriate for the alert at hand, but which may have been useful in other alerts. The drug name itself probably already triggered rules before alerts were read properly. Length, content, and sequence of the alert texts provided by the Dutch national database have been mentioned negatively in another study as well [7]. Unambiguous, concise and easy-to-understand alerts, with easily accessible background information would add to usefulness of the alerts [1,7,19- 22]. Insufficient training also appeared to play a role. Several respondents did not know that serotonin syndrome is a serious adverse event, and did not recognize the sequence of ordering captopril or furosemide as an important risk factor. Training is proposed as an important remedy to reduce misinterpretation. Concise alert texts may add to better understanding by provid-
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ing informal training in the limited time during order entry, but easily accessible additional information is mentioned as an important factor for useful alerts also [19-21].
Wrong selection
A few times respondents made a wrong selection, because they trusted the alerting system (and followed the incorrect dose recommendation for an unfamiliar drug), because the alert presentation was unclear (two DDI alerts in one screen provoking oversight) or because the frequently-overridden DDI was generally irrelevant (DDI captopril-furosemide). By similarity matching and frequency gambling this resulted in the very strong rule that this latter DDI was irrelevant and did not require any specific action besides blood pressure monitoring. The introduction of sequence indications is proposed to improve specificity and prevent this type of error, but this should be accompanied by adequate information and monitoring because it is difficult to change RB behavior based on such a strong rule.
Latent conditions
Besides insufficient training, other latent conditions that may have caused errors in handling drug safety alerts were dependency on the alerting system and trust in checks by other people [1]. Dependency on the alerting system could not be proven in this study. One resident men- tioned that judging drug safety alerts was not a surgeon’s job, thereby relying on other people. These comments suggest that responsibility for alert handling is probably not clearly and suf- ficiently communicated to the users.