Patient safety vs. physician frustration: Finding a balance for medication alerts

Warnings in a computerized provider order entry system help alert prescribers to risky drugs for the elderly.

Elderly patients face many dangers during a hospitalization. Adverse drug events that result from inappropriate prescribing would appear to be one of the most avoidable, yet they occur in up to 40% of inpatient stays, according to some studies.

Geriatricians at Beth Israel Deaconess Medical Center in Boston decided to do something about this problem using their existing computerized provider order entry (CPOE) system. With the help of a pharmacist and computer programmer, the hospital developed a warning system for its CPOE that would alert any prescriber who selects a medication that poses particular risk to elderly patients.

Photo courtesy of Dr Mattison
Photo courtesy of Dr. Mattison.

Three years after implementation, the use of these medications had dropped, according to results published in Archives of Internal Medicine in August. Lead author Melissa L.P. Mattison, ACP Member, recently spoke with ACP Hospitalist about the warning system's effects and what other hospitals and hospitalists can learn from her experience.

Q: What motivated the development of your warning system?

A: Many physicians have not had special training in geriatric medicine. There is a list of medications that are considered potentially inappropriate in older patients called the Beers list published first in the early 1990's and updated several times since. We felt it was important to warn staff when they were ordering one of the Beers medications, to let them know that it may not be well-tolerated.

Q: How did you create the system?

A: I inherited the idea from one of my colleagues who actually thought of the warning system but then moved to another city before she had the opportunity to create it. I worked with a pharmacist and one of the developers from our IT department. We were deliberate in choosing medications from the Beers list that were commonly ordered in the inpatient setting, available on our formulary, and for which there were alternative medications available.

Q: What do the warnings entail?

A: The warnings only come up for patients who are 65 and older on a subset of the Beers medications. With the warning system, when an ordering provider attempts to order one of these targeted medications, they are taken to a screen in the CPOE system that provides them with the text from the Beers article explaining the particular hazard for that medication. The ordering provider has the option of bypassing the warning and continuing to order the medication, or they may reconsider and choose an alternate medication.

Q: What was the response to the new system?

A: We tested the warning system for three months, using just five medications. There were no complaints about the system and we did see a trend to decreased usage during that time. The warning system was turned on for the remaining medications after the testing period and has been on ever since.

Q: Your study found that the mean rate of medication orders for these drugs dropped from 11.56 orders per day to 9.94. How did those results compare with your expectations?

A: We were pleased that there are over 20% fewer of these potentially inappropriate medications being ordered now than before the warning system was developed.

Q: Why are so many alerts bypassed?

A: One of the problems with a lot of these warning systems…is that of alert fatigue, whereby users tire of seeing warnings and stop reading them altogether. Some studies have found over 90% of warnings are bypassed. We were deliberate in placing warnings on only some of the Beers medications, those that we felt had legitimate alternatives.

Q: How do you find the proper balance between the benefits of alerts and the risk of alert fatigue?

A: This is something many in the field are working on. It's a tough balance but one that eventually I hope we reach.

Q: What lessons can others take from your experience?

A: Since many institutions will buy a commercially available CPOE system, they may not be able to tailor it to their own unique circumstances. Yet, it seems important to pick a CPOE system that allows some flexibility around local systems of care.

Q: Do alert systems need to be customized to individual hospitals, or just generally have fewer warnings?

A: I don't know. Not everybody should have to reinvent the wheel, individual hospital by individual hospital. Maybe store-bought systems could contain aspects of this kind of targeted intervention.

Q: What's next for your program—customized alerts for other patient groups, other geriatrics interventions?

A: We've actually started a comprehensive new program called GRACE (the Global Risk Assessment and Careplan for Elders). It's an effort to try to standardize the care for older patients hospital-wide using the computer systems (including applications used by physicians, nurses and pharmacists) and a bedside care form.

Q: How has GRACE further changed the CPOE system?

A: One part of GRACE is a new standardized screen within CPOE to guide appropriate analgesic dosing in older patients. We have also created a standard screen to help with antipsychotic ordering in older patients. We wanted to help guide clinicians to the proper indications for using these medications and the proper dosage. One of the things that we really would like to do is make our hospital as safe as possible for older patients.