A trial of automated decision support alerts for contraindicated medications using computerized physician order entry

Abstract

Background: Automated clinical decision support has shown promise in reducing medication errors; however, clinicians often do not comply with alerts. Because renal insufficiency is a common source of medication errors, the authors studied a trial of alerts designed to reduce inpatient administration of medications contraindicated due to renal insufficiency.

Methods: A minimum safe creatinine clearance was established for each inpatient formulary medication. Alerts recommending cancellation appeared when a medication order was initiated for a patient whose estimated creatinine clearance was less than the minimum safe creatinine clearance for the medication. Administration of medications in patients with creatinine clearances less than the medication's minimum safe clearance were studied for 14 months after, and four months before, alert implementation. In addition, the impact of patient age, gender, degree of renal dysfunction, time of day, and duration of housestaff training on the likelihood of housestaff compliance with the alerts was examined.

Results: The likelihood of a patient receiving at least one dose of contraindicated drug after the order was initiated decreased from 89% to 47% (p < 0.0001) after alert implementation. Analysis of the alerts seen by housestaff showed that alert compliance was higher in male patients (57% vs. 38%, p = 0.02), increased with the duration of housestaff training (p = 0.04), and increased in patients with worsening renal function (p = 0.007).

Conclusion: Alerts were effective in decreasing the ordering and administration of drugs contraindicated due to renal insufficiency. Compliance with the alerts was higher in male patients, increased with the duration of housestaff training, and increased in patients with more severe renal dysfunction.

Figure 1.

Example of a contraindication alert. This alert is displayed to the ordering clinician upon initiation of an order for a contraindicated medication only when the most recent CrCl_est is below a previously determined safe value. Clicking “OK” does not automatically discontinue the medication order. This example is for an order for the drug metformin in a mock patient with a CrCl_est of 34.3 mL/min.

Figure 2.

Compliance versus duration of housestaff training. The y-axis represents the percentage of housestaff compliant with the alert recommendation to discontinue an order for a contraindicated drug. The x-axis represents the duration of housestaff training from the beginning of their residency until the time that the alert was received in months.