Appropriateness of commercially available and partially customized medication dosing alerts among pediatric patients.

Jeremy S. Stultz; Milap C. Nahata

Study

Appropriateness of commercially available and partially customized medication dosing alerts among pediatric patients.

April 2, 2014

Stultz JS, Nahata MC. J Am Med Inform Assoc. 2014;21(e1):e35-42.

View more articles from the same authors.

In this retrospective review of pediatric medication alerts, more than 85% of dosing alerts presented to clinicians were inappropriate. Frequent incorrect alerts contribute to alert fatigue and make clinicians more likely to override appropriate warnings.

PubMed citation

Free full text

Related Resources From the Same Author(s)

Preventability of voluntarily reported or trigger tool–identified medication errors in a pediatric institution by information technology: a retrospective cohort study.

June 10, 2015

Computerized clinical decision support for medication prescribing and utilization in pediatrics.

September 26, 2012

Identification and characterization of adverse drug events in primary care.

October 11, 2017

Provider and patient perceptions of an external medication history function.

August 5, 2015

mHealth and mobile medical apps: a framework to assess risk and promote safer use.

March 1, 2017

Patient safety indicators for England from hospital administrative data: case-control analysis and comparison with US data.

November 5, 2008

Making electronic prescribing alerts more effective: scenario-based experimental study in junior doctors.

August 31, 2011

Checklists change communication about key elements of patient care.

October 10, 2012

Perceptions of rounding checklists in the intensive care unit: a qualitative study.

May 9, 2018

Assessment of the use of patient vital sign data for preventing misidentification and medical errors.

January 25, 2023

How can the criminal law support the provision of quality in healthcare?

April 16, 2014

The impact of health system membership on patient safety initiatives.

January 9, 2008

Enhancing patient safety with intelligent intravenous infusion devices: experience in a specialty cardiac hospital.

November 9, 2011

Treatment patterns and clinical outcomes after the introduction of the Medicare Sepsis Performance Measure (SEP-1).

May 5, 2021

Assessment of the potential impact of a reminder system on the reduction of diagnostic errors: a quasi-experimental study.

May 17, 2006

Ambiguities of chronic illness management and challenges to the medical error paradigm.

November 8, 2006

Implementation of diagnostic pauses in the ambulatory setting.

February 14, 2018

The nuclear power industry as an alternative analogy for safety in anaesthesia and a novel approach for the conceptualisation of safety goals.

November 2, 2005

Sepsis quality in safety-net hospitals: an analysis of Medicare's SEP-1 performance measure.

October 2, 2019

State sepsis mandates—a new era for regulation of hospital quality.

June 21, 2017

Risk management in radiology departments.

July 15, 2015

The effect of multidisciplinary care teams on intensive care unit mortality.

March 3, 2010

Role of medical students in preventing patient harm and enhancing patient safety.

August 16, 2006

Returning to the roots of culture: a review and re-conceptualisation of safety culture.

June 5, 2013

Using a medical emergency team to manage anaphylactic shock.

June 4, 2008

Standardized sign-out reduces intern perception of medical errors on the general internal medicine ward.

April 15, 2009

The investigation and analysis of critical incidents and adverse events in healthcare.

May 25, 2005

The evolution of patient safety procedures in an oral surgery department

December 11, 2019

Qualities and attributes of a safe practitioner: identification of safety skills in healthcare.

January 26, 2011

An appeal for evidence-based resident duty hours reform.

September 27, 2017

Defining the technical skills of teamwork in surgery.

August 16, 2006

Embedding quality improvement and patient safety - the UCLA value analysis experience.

April 18, 2007

Comparative, cross-sectional study of the format, content and timing of medication safety letters issued in Canada, the USA and the UK.

November 7, 2018

Improving transitions of care for patients on warfarin: the Safe Transitions Anticoagulation Report.

October 7, 2015

Computerized physician order entry of injectable antineoplastic drugs: an epidemiologic study of prescribing medication errors.

October 6, 2010

Framework for analysing risk and safety in clinical medicine.

July 17, 2013

Framework for analysing risk and safety in clinical medicine.

July 17, 2013

An experimental study in nurse-physician relationships.

August 2, 2006

Analysing potential harm in Australian general practice: an incident-monitoring study.

March 27, 2005

Ambulance personnel perceptions of near misses and adverse events in pediatric patients.

August 11, 2010

Computerized surveillance of adverse drug events in hospital patients.

March 27, 2005

Postdischarge adverse events for 1-day hospital admissions in older adults admitted from the emergency department.

April 7, 2010

Striving for a zero-error patient surgical journey through adoption of aviation-style challenge and response flow checklists: a quality improvement project.

February 27, 2013

Knowledge-based errors in anesthesia: a paired, controlled trial of learning and retention.

March 18, 2009

Validation of a mobile app for reducing errors of administration of medications in an emergency.

June 19, 2019

Patient safety events reported in general practice: a taxonomy.

March 5, 2008

Start using a checklist, PRONTO: recommendation for a standard review process for chemotherapy orders.

March 13, 2019

Incidence of potentially avoidable urgent readmissions and their relation to all-cause urgent readmissions.

September 28, 2011

Intra-operative monitoring—many alarms with minor impact.

September 18, 2013

Medication error reporting in nursing homes: identifying targets for patient safety improvement.

February 17, 2010

ProvenCare: quality improvement model for designing highly reliable care in cardiac surgery.

October 28, 2009

A human factors engineering paradigm for patient safety: designing to support the performance of the healthcare professional.

December 20, 2006

Computer based medication error reporting: insights and implications.

June 21, 2006

Case 34-2010: a 65-year-old woman with an incorrect operation on the left hand.

November 17, 2010

Parents as partners in obtaining the medication history.

June 29, 2005

Should operations be regionalized? The empirical relation between surgical volume and mortality.

March 6, 2005

Chief resident for quality improvement and patient safety: a description.

July 2, 2014

Reducing anticoagulant medication adverse events and avoidable patient harm.

April 9, 2008

Adverse drug events in hospitalized patients: excess length of stay, extra costs, and attributable mortality.

March 27, 2005

Analysis and prioritization of near-miss adverse events in a radiology department.

May 11, 2011

Educational interventions to reduce prescribing errors.

May 7, 2008

Effects of shift length on quality of patient care and health provider outcomes: systematic review.

June 10, 2009

Medication errors in paediatric outpatients.

September 8, 2010

Exploring the impact of safety culture on incident reporting: lessons learned from machine learning analysis of NHS England staff survey and incident data.

August 30, 2023

Failure to weigh patients in hospital: a medication safety risk.

September 12, 2007

Psychometric properties of the Hospital Survey on Patient Safety Culture: findings from the UK.

May 5, 2010

Hospital admission medication reconciliation in medically complex children: an observational study.

April 21, 2010

Emergency hospitalizations for adverse drug events in older Americans.

December 7, 2011

Detection rates of mild cognitive impairment in primary care for the United States Medicare population.

November 15, 2023

A reduction in cardiac arrests and duration of clinical instability after implementation of a paediatric rapid response system.

December 16, 2009

Changing dynamics of the drug overdose epidemic in the United States from 1979 through 2016.

October 10, 2018

What can we learn about patient safety from information sources within an acute hospital: a step on the ladder of integrated risk management?

June 25, 2008

Effectiveness of a graduate medical education program for improving medical event reporting attitude and behavior.

October 12, 2005

Facilitated self-reported anaesthetic medication errors before and after implementation of a safety bundle and barcode-based safety system.

February 13, 2019

Effect of point-of-care computer reminders on physician behaviour: a systematic review.

March 24, 2010

Alterations in Spanish language interpretation during pediatric critical care family meetings.

December 6, 2017

Implementation of an electronic system for medication reconciliation.

February 28, 2007

Simulation based teamwork training for emergency department staff: does it improve clinical team performance when added to an existing didactic teamwork curriculum?

April 5, 2006

Impact of the World Health Organization's Surgical Safety Checklist on safety culture in the operating theatre: a controlled intervention study.

July 10, 2013

Medication prescribing and monitoring errors in primary care: a report from the Practice Partner Research Network.

November 17, 2010

Second victims need emotional support after adverse events: even in a just safety culture.

April 3, 2019

Understanding and preventing vaccination errors.

May 31, 2023

Failure events in transition of care for surgical patients.

March 5, 2014

Overarching goals: a strategy for improving healthcare quality and safety?

December 19, 2012

Measuring safety climate in health care.

April 19, 2006

The impact of traditional and smart pump infusion technology on nurse medication administration performance in a simulated inpatient unit.

May 26, 2010

Why the nation needs a policy push on patient-centered health care.

August 18, 2010

Preventable anesthesia mishaps: a study of human factors.

March 27, 2005

A classification system for incidents and accidents in the health-care system.

March 6, 2005

Medication error prevention by pharmacists.

March 6, 2005

Testing process errors and their harms and consequences reported from family medicine practices: a study of the American Academy of Family Physicians National Research Network.

June 11, 2008

Inter-rater reliability of a classification system for hospital adverse drug event reports.

September 12, 2007

Psychological safety in intensive care unit rounding teams.

July 21, 2021

Cognitive error in an academic emergency department.

October 10, 2018

Parent preferences for medical error disclosure: a qualitative study.

February 1, 2017

Safe practices for copy and paste in the EHR. Systematic review, recommendations, and novel model for health IT collaboration.

February 8, 2017

Controversy and quality improvement: lingering questions about ethics, oversight, and patient safety research.

May 28, 2008

Multimodal system designed to reduce errors in recording and administration of drugs in anaesthesia: prospective randomised clinical evaluation.

October 5, 2011

The culture of safety: results of an organization-wide survey in 15 California hospitals.

March 6, 2005

Design and implementation of an application and associated services to support interdisciplinary medication reconciliation efforts at an integrated healthcare delivery network.

December 6, 2006

Related Resources

Impact of a computerized physician order entry system on medication safety in pediatrics-The AVOID study.

June 7, 2023

Using sociotechnical theory to understand medication safety work in primary care and prescribers' use of clinical decision support: a qualitative study.

May 24, 2023

Interview

In Conversation with Susan McGrath, PhD and George Blike, MD about Surveillance Monitoring

April 26, 2023

Perspective

Surveillance Monitoring to Improve Patient Safety in Acute Hospital Care Units

April 26, 2023

Improving medication safety in a paediatric hospital: a mixed-methods evaluation of a newly implemented computerised provider order entry system.

April 12, 2023

Indication documentation and indication-based prescribing within electronic prescribing systems: a systematic review and narrative synthesis.

April 5, 2023

Perspectives on Safety

Annual Perspective

Technology as a Tool for Improving Patient Safety

March 29, 2023

WebM&M Cases

Overdose of Gabapentin and Oxycodone in a Patient with End-Stage Renal Disease: A Case for Appropriate Interruptive Drug-Disease Alerts.

February 1, 2023

Short- and long-term effects of an electronic medication management system on paediatric prescribing errors.

January 18, 2023

Scaling-up a pharmacist-led information technology intervention (PINCER) to reduce hazardous prescribing in general practices: multiple interrupted time series study.

January 11, 2023

Health system redesign of cardiac monitoring oversight to optimize alarm management, safety, and staff engagement.

December 14, 2022

Overriding drug-drug interaction alerts in clinical decision support systems: a scoping review.

September 7, 2022

The potential for leveraging machine learning to filter medication alerts.

May 4, 2022

Improving the specificity of drug-drug interaction alerts: can it be done?

April 6, 2022

Annual Perspective

Annual Perspective: Topics in Medication Safety

March 31, 2022

Alert burden in pediatric hospitals: a cross-sectional analysis of six academic pediatric health systems using novel metrics.

November 3, 2021

Applying human factors engineering to address the telemetry alarm problem in a large medical center.

August 11, 2021

The effectiveness of interruptive prescribing alerts in ambulatory CPOE to change prescriber behaviour and improve safety.

May 5, 2021

The development and piloting of the Ambulatory Electronic Health Record Evaluation Tool: lessons learned.

March 17, 2021

Safe Practices to Reduce CPOE Alert Fatigue through Monitoring, Analysis, and Optimization.

March 10, 2021

Renal medication-related clinical decision support (CDS) alerts and overrides in the inpatient setting following implementation of a commercial electronic health record: implications for designing more effective alerts.

February 17, 2021

A qualitative study of prescribing errors among multi-professional prescribers within an e-prescribing system.

December 23, 2020

A machine learning-based clinical decision support system to identify prescriptions with a high risk of medication error.

October 21, 2020

Emergency department monitor alarms rarely change clinical management: an observational study.

September 16, 2020

The tradeoffs between safety and alert fatigue: data from a national evaluation of hospital medication-related clinical decision support.

July 29, 2020

Assessment of health information technology-related outpatient diagnostic delays in the US Veterans Affairs health care system: a qualitative study of aggregated root cause analysis data.

July 22, 2020

The impact of technology on prescribing errors in pediatric intensive care: a before and after study.

June 3, 2020

Time series evaluation of improvement interventions to reduce alarm notifications in a paediatric hospital.

February 12, 2020

Assessment of unintentional duplicate orders by emergency department clinicians before and after implementation of a visual aid in the electronic health record ordering system.

January 22, 2020

Team-based intervention to reduce the impact of nonactionable alarms in an adult intensive care unit.

November 6, 2019

See More About The Topic

Hospitals

Children's Hospitals

Ambulatory Clinic or Office

Physicians

Information Professionals

Appropriateness of commercially available and partially customized medication dosing alerts among pediatric patients.

Connect With Us

Sign up for Email Updates

Agency for Healthcare Research and Quality

Appropriateness of commercially available and partially customized medication dosing alerts among pediatric patients.

Connect With Us

Sign up for Email Updates

Agency for Healthcare Research and Quality

Submit Your Innovations

Continue as a Guest

Continue Logged In

Submit Your Innovations

Continue as a Guest

Continue logged in

New Users to the PSNet site