A patient dies in the hospital after a rare but fatal adverse event related to a drug-drug interaction. In response, the hospital implements a more comprehensive database of drug-drug interactions in its computerized order entry system. The updated database increases the number of recognized drug interactions from 60,000 to 200,000. A year later, however, the quality improvement team finds that the number of prescribed drugs with high-risk interactions has increased since the database update.
Which of the following is the most likely explanation for this finding?

Question

A patient dies in the hospital after a rare but fatal adverse event related to a drug-drug interaction.  In response, the hospital implements a more comprehensive database of drug-drug interactions in its computerized order entry system.  The updated database increases the number of recognized drug interactions from 60,000 to 200,000.  A year later, however, the quality improvement team finds that the number of prescribed drugs with high-risk interactions has increased since the database update.
Which of the following is the most likely explanation for this finding?

Quizplus · Accepted Answer

11ec193a_972b_a49b_853d_e1fff086a894_MD0002_00 This case study illustrates an example of alert fatigue, a recognized adverse effect of electronic health records, order entry systems, and other computerized devices. Alert fatigue occurs when health care personnel are bombarded by numerous automated alerts and warnings of low clinical consequence (ie, low signal-to-noise ratio) and become conditioned to ignore all alerts, including those with high clinical significance. A study in an intensive care unit found an average of >180 audible alarms/bed/day, the large majority of which were clinically inconsequential. Automated alerts are commonly utilized in health care settings, with some types (eg, drug-drug interactions) mandated by regulations regarding electronic health records; their use has been associated with decreased medication error rates. However, the realized benefits tend to be more modest than anticipated, possibly due to high override rates. To mitigate the risk of alert fatigue, it is recommended that health care facilities measure clinically meaningful outcomes before and after implementing or changing alerting systems. Specific recommendations are listed in the table. (Choice B) Excessive work hours (eg, resident physician on-call schedules) or workloads are associated with an increased frequency of medical errors. However, alert fatigue can occur with any change in workflow even if workload is held constant. (Choice C) Overutilization refers to excessive health care consumption by individual patients, leading to use of diagnostic tests and treatments that do not improve outcomes. Overutilization would lead to reduced benefit per service rather than increased error rate. (Choice D) Interoperability refers to the capacity of one system to interact correctly with another. An example of poor interoperability would be a new computerized order entry system that does not give proper commands to an automated pharmacy dispensing system. (Choice E) Risk homeostasis is the tendency to compensate for a decline in risk in one area with an increase in risk taking in another. An example would be an increase in unsafe driving habits after buying a car with upgraded airbags and safety systems. Educational objective: Alert fatigue occurs when health care personnel are bombarded by numerous automated alerts and warnings of low clinical consequence and become conditioned to ignore all alerts, including those with high clinical significance. __________ References: Recommendations to improve the usability of drug-drug interaction clinical decision support alerts. (http://www.ncbi.nlm.nih.gov/pubmed/25829460) Insights into the problem of alarm fatigue with physiologic monitor devices: a comprehensive observational study of consecutive intensive care unit patients. (http://www.ncbi.nlm.nih.gov/pubmed/25338067)

A Patient Dies in the Hospital After a Rare but Fatal