How to design computerized alerts to safe prescribing practices

Jt Comm J Qual Saf. 2004 Nov;30(11):602-13. doi: 10.1016/s1549-3741(04)30071-7.


Background: Medication errors and preventable adverse drug events are common, and about half of medication errors occur during medication ordering. This study was designed to develop and evaluate medication safety alerts and processes for educating prescribers about the alerts.

Methods: At Kaiser Permanente Northwest, a group-model health maintenance organization where prescribers have used computerized order entry since 1996, qualitative interviews were conducted with 20 primary care prescribers.

Results: Prescribers considered alerts helpful for providing prescribing and preventive health information. More than half the interviewees stated that it would be unwise to let clinicians control or avoid safety alerts. Common frustrations were (1) being delayed by the alert, (2) having difficulty interpreting the alert, and (3) receiving the same alert repeatedly. Most prescribers preferred small-group educational sessions tied to existing meetings and having local physicians conduct education sessions.

Discussion: The findings were used to design a strategy for introducing and promoting the interventions, modifying the alert text and tools, and focusing the education on how clinicians could use the alerts effectively.

Publication types

  • Multicenter Study
  • Research Support, U.S. Gov't, P.H.S.

MeSH terms

  • Attitude of Health Personnel
  • Clinical Pharmacy Information Systems*
  • Computer User Training
  • Decision Support Systems, Clinical*
  • Efficiency, Organizational
  • Female
  • Health Maintenance Organizations / standards*
  • Humans
  • Interviews as Topic
  • Male
  • Medical Staff / education
  • Medical Staff / psychology
  • Medication Errors / prevention & control*
  • Oregon
  • Reminder Systems*
  • Safety Management
  • Washington