Tiering drug-drug interaction alerts by severity increases compliance rates

Abstract

Objective: Few data exist measuring the effect of differentiating drug-drug interaction (DDI) alerts in computerized provider order entry systems (CPOE) by level of severity ("tiering"). We sought to determine if rates of provider compliance with DDI alerts in the inpatient setting differed when a tiered presentation was implemented.

Design: We performed a retrospective analysis of alert log data on hospitalized patients at two academic medical centers during the period from 2/1/2004 through 2/1/2005. Both inpatient CPOE systems used the same DDI checking service, but one displayed alerts differentially by severity level (tiered presentation, including hard stops for the most severe alerts) while the other did not. Participants were adult inpatients who generated a DDI alert, and providers who wrote the orders. Alerts were presented during the order entry process, providing the clinician with the opportunity to change the patient's medication orders to avoid the interaction.

Measurements: Rate of compliance to alerts at a tiered site compared to a non-tiered site.

Results: We reviewed 71,350 alerts, of which 39,474 occurred at the non-tiered site and 31,876 at the tiered site. Compliance with DDI alerts was significantly higher at the site with tiered DDI alerts compared to the non-tiered site (29% vs. 10%, p < 0.001). At the tiered site, 100% of the most severe alerts were accepted, vs. only 34% at the non-tiered site; moderately severe alerts were also more likely to be accepted at the tiered site (29% vs. 10%).

Conclusion: Tiered alerting by severity was associated with higher compliance rates of DDI alerts in the inpatient setting, and lack of tiering was associated with a high override rate of more severe alerts.

Figure 1

Level 1 Alert, requiring one of the orders to be stopped. Since these alerts are presented at the time a drug is selected for ordering, in this example no order for lsosorbid Dinitrate has yet been written, allowing the order process to be canceled. Sildenafil has previously been ordered for this patient, however, and a discontinue order must be created, which the CPOE system will do when this option is selected.

Figure 2

Level 2 Alert with Override Reasons. As with the non-tiered site alerts, the clinician may choose either to keep both orders or stop one of them, and is required to choose a reason for continuing both.

Figure 3

Level 3 Alert. These alerts use available screen real estate and require no action at all, not even clicking an “Ok” button. The figure shows how it fits into the medication ordering screen, with an enlarged version of the alert area itself provided for clarity.

Figure 4

Non-tiered DDI alert screen. All alerts for the drug being ordered appear on this screen. Scrolling through the “Warnings” box displays individual messages for each alert. The action selected (Cancel or Keep) affects all the alerts shown. Selecting “Keep” opens a text box and requires a reason to be supplied.