For e-prescribing to reduce medical errors, alerts cannot be ignored

E-prescribing can reduce medical errors and improve quality of care, but doctors and clinicians must stop ignoring alerts from clinical decision support software, studies show.

Electronic prescribing, also known as e-prescribing, is a bedrock element of the federal government's push for health IT. So is clinical decision support software, which warns physicians when they are about to prescribe combinations of drugs with dangerous interactions, drugs to which a patient is allergic, or drugs that are inappropriate for pregnant or breast-feeding patients.

Used together, the two tools can reduce some healthcare providers' medical errors by a factor of seven, according to a study by Dr. Rainu Kaushal, associate professor at Weill Cornell Medical College, and her colleagues. The study was funded by the National Institutes of Health and published earlier this year in the Journal of General Internal Medicine.

The study compared almost 4,000 prescriptions from 30 providers. Half were filled electronically, and half used a paper workflow. Kaushal's team discovered that small ambulatory group practices and community-based hospitals seem more prone to making medication errors than are teaching hospitals affiliated with a university. Because small group practices and community hospitals so far have lagged in adopting e-prescribing tools, their patients may have more to gain from their use.

It gives appropriate suggestions at the correct time, when a prescribing physician needs it, so that they don't have to actively leave their workflow. … [I]nformation is actively being pushed to them.
Dr. Rainu Kaushalassociate professor, Weill Cornell Medical College

"It's a little early to start hypothesizing why that is," Kaushal said. "We want to do more to understand it."

The study's authors broke down prescribing errors into three categories:

  • Illegibility errors that stem from unreadable or easily misinterpreted handwriting strokes. E-prescribing eliminated physician handwriting, and therefore reduced illegibility errors to zero in Kaushal's study.
  • Rule violations, such as writing a prescription without stating a dose or indicating which health condition required the drug. Such violations typically are not harmful to the patient, but they sometimes result in follow-up calls to get the information corrected -- and that taxes a provider's bandwidth. Rule violations were nearly eliminated with e-prescribing.
  • Near misses, which are potentially harmful errors -- such as prescribing a drug to which the patient is allergic but catching it before the patient is harmed. These were few in number to begin with, but the researchers concluded that clinical decision support software makes most near misses preventable.

Choosing to purchase a good clinical decision support software to go with e-prescribing can help physicians and hospitals prevent prescribing errors. But how do you know a well-designed clinical decision support system when you see it?

"It gives appropriate suggestions at the correct time, when a prescribing physician needs it, so that they don't have to actively leave their workflow and go, for example, to the Physicians' Desk Reference and look something up. The information is actively being pushed to them," Kaushal said in an interview with, adding that "appropriate suggestions" are tailored to the patient being seen at that time. Effectiveness also improves when vendors of clinical decision support systems provide rigorous technical support, she said.

Clinical decision support software should not be ignored

If Kaushal's research sites were any indication of national trends, regional extension centers funded by the HITECH Act will play a large role in improving healthcare quality by helping physicians learn to prevent errors with clinical decision support software.

That point speaks to the result of another study, published in the February 2009 issue of the Archives of Internal Medicine. After analyzing 3.5 million prescriptions filed in 2006, the authors concluded that doctors disregard alerts from clinical decision support software a majority of the time. Sometimes, alerts are ignored due to alert fatigue. In other cases, doctors prefer to rely on their own judgment.

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Ultimately, participants in the study treated the software as more of a nuisance than an asset. Clinicians, the researchers found, ignored more than 90% of drug interaction alerts and 77% of drug allergy alerts. They typically dismissed drug interaction alerts -- even those rated with high severity -- for medications commonly used in combination to treat specific diseases. They also were less likely to accept an alert if the patient had been treated with the medication previously.

"Electronic prescribing clearly will improve medication safety, but its full benefit will not be realized without the development and integration of high-quality decision support systems to help clinicians better manage medication safety alerts," said Dr. Saul Weingart, the study's senior author and vice president for patient safety at Boston-based Dana-Farber Cancer Institute and Beth Israel Deaconess Medical Center, in a statement.

Let us know what you think about the story; email Don Fluckinger, Features Writer.

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