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PSNet: Patient Safety Network
Journal Article

Automated identification of antibiotic overdoses and adverse drug events via analysis of prescribing alerts and medication administration records.

Kirkendall ES, Kouril M, Dexheimer JW, et al. Journal of the American Medical Informatics Association. 2016.

The availability of decision support in computerized provider order entry (CPOE) systems has improved the ability to detect and prevent medication errors before they reach patients. However, when CPOE systems generate an excessive number of safety warnings that prescribers must manually override, alert fatigue may occur. In this study, investigators used a trigger tool approach and reviewed all antibiotic prescriptions with overridden alerts. They found that antibiotic prescriptions with overridden alerts were associated with dosing errors. In many cases, antibiotic overdoses reached patients and led to symptoms. The investigators used this data to refine the alert system, which eliminated some useless alerts. The authors conclude that automated algorithm-based detection systems can enhance the relevance of CPOE medication alerts and thereby reduce medication errors. A recent WebM&M commentary described a medication overdose related to alert fatigue.