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Orenstein EW, Kandaswamy S, Muthu N, et al. J Am Med Inform Assoc. 2021;28(12):2654-2660.
Alert fatigue is a known contributor to medical error. In this cross-sectional study, researchers found that custom alerts were responsible for the majority of alert burden at six pediatric health systems. This study also compared the use of different alert burden metrics to benchmark burden across and within institutions.
Sibbald M, Monteiro SD, Sherbino J, et al. BMJ Qual Saf. 2021;Epub Oct 5.
Diagnostic safety remains a patient safety priority. This randomized study including emergency medicine and internal medicine physicians as well as medical students found that electronic differential diagnostic support increased the likelihood that the correct diagnosis appeared in the differential, regardless of whether the tool was used early or late in the diagnostic process.
Maxwell E, Amerine J, Carlton G, et al. Am J Health Syst Pharm. 2021;78(Suppl 3):s88-s94.
Clinical decision support (CDS) tools are intended to enhance care decision and delivery processes. This single-site retrospective study evaluated whether a CDS tool can reduce discharge prescription errors for patients receiving a medication substitution at admission. Findings indicate that use of CDS did not result in a decrease in discharge prescription omissions, duplications, or inappropriate medication reconciliation.
Slikkerveer M, van de Plas A, Driessen JHM, et al. J Patient Saf. 2021;17(7):e587-e592.
Anticoagulants, such as low-molecular-weight heparin (LMWH), are known to be high-risk for adverse drug events. This cross-sectional study identified prescribing errors – primarily lack of dosage adjustment for body weight and/or renal function – among one-third of LMWH users admitted to one hospital over a five-month period.

A 31-year-old woman presented to the ED with worsening shortness of breath and was unexpectedly found to have a moderate-sized left pneumothorax, which was treated via a thoracostomy tube. After additional work-up and computed tomography (CT) imaging, she was told that she had some blebs and mild emphysema, but was discharged without any specific follow-up instructions except to see her primary care physician.

Koeck JA, Young NJ, Kontny U, et al. Paediatr Drugs. Epub 2021 May 8. 

Pediatric patients are at risk for medication prescribing errors due to weight-based dosing. This review analyzed 70 interventions aimed at reducing weight-based prescribing errors. Findings indicate that bundled interventions are most effective, and that interventions should include substitute or engineering controls (e.g., computerized provider order entry) along with administrative controls (e.g., expert consultation).

A 24-year-old woman with type 1 diabetes presented to the emergency department with worsening abdominal pain, nausea, and vomiting. Her last dose of insulin was one day prior to presentation. She stopped taking insulin because she was not tolerating any oral intake. The admitting team managed her diabetes with subcutaneous insulin but thought the patient did not meet criteria for diabetic ketoacidosis (DKA), but after three inpatient days with persistent hyperglycemia, blurred vision, and altered mental status, a consulting endocrinologist diagnosed DKA.

Cattaneo D, Pasina L, Maggioni AP, et al. Drugs Aging. 2021;38(4):341-346.
Older adults are at increased risk of hospitalization due to COVID-19 infections. This study examined the potential severe drug-drug interactions (DDI) among hospitalized older adults taking two or more medications at admission and discharge. There was a significant increase in prescription of proton pump inhibitors and heparins from admission to discharge. Clinical decision support systems should be used to assess potential DDI with particular attention paid to the risk of bleeding complications linked to heparin-based DDIs.
Vasey B, Ursprung S, Beddoe B, et al. JAMA Netw Open. 2021;4(3):e211276.
This study explored the role of machine-learning based clinical decision support (CDS) algorithms to support (rather than replace) human decision-making and the impact on diagnostic performance. This systematic review of 37 studies found limited evidence that the use of machine learning-based CDS systems contributes to improved diagnostic performance among clinicians. Interobserver agreement, user feedback, and clinician override were the most commonly reported outcomes. The authors emphasize the importance of further evaluation of human-computer interaction.
Kostopoulou O, Tracey C, Delaney BC. J Am Med Inform Assoc. 2021;28(7):1461-1467.
In addition to being used for patient-specific clinical purposes, data within the electronic health record (EHR) may be used for other purposes including epidemiological research. Researchers in the UK developed and tested a clinical decision support system (CDSS) to evaluate changes in the types and number of observations that primary care physicians entered into the EHR during simulated patient encounters. Physicians documented more clinical observations using the CDSS compared to the standard electronic health record. The increase in documented clinical observations has the potential to improve validity of research developed from EHR data.
Co Z, Holmgren AJ, Classen DC, et al. Appl Clin Inform. 2021;12(01):153-163.
Medication errors occur frequently in ambulatory care settings. This article describes the development and testing of an ambulatory medication safety evaluation tool, which is based on an inpatient version administered by The Leapfrog Group. Pilot testing at seven clinics around the US indicates that clinics struggled in areas of advanced decision support such as drug age and drug monitoring, and that most clinics lacked EHR-based medication reconciliation functions.

Partnership for Health IT Patient Safety. Plymouth Meeting, PA: ECRI Institute; 2021.

Alert fatigue is a recognized contributor to task burden and medical error. This report distilled monitoring, analysis, and optimization experiences to recommend strategies for improving the effectiveness of clinical audible alerts which includes the development of an overarching clinical decision support governance plan.

Trauma staff at The Alfred Hospital use a computerized decision support system to guide the care of patients during the critical first 60 minutes of resuscitation. Known as the Trauma Reception and Resuscitation System (TR&R®), this program generates prompts based on more than 40 algorithms and real-time clinical data, including patient vital signs and information entered by a trauma nurse. Displayed on a large overhead monitor, these prompts are used by clinicians to direct the care of trauma patients and to facilitate documentation and communication. The program reduced overall medical errors, along with the incidence of several specific types of mistakes, including aspiration pneumonia (caused by entrance of foreign materials into the bronchial tree) and errors during management of shock.

Shah SN, Amato MG, Garlo KG, et al. J Am Med Inform Assoc. 2021;28(6):1081-1087.
Clinical decision support (CDS) alerts can improve patient safety, and prior research suggests that monitoring alert overrides can identify errors. Over a one-year period, this study found that medication-related CDS alerts associated with renal insufficiency were nearly always deemed inappropriate and were all overridden. These findings highlight the need for improvements in alert design, implementation, and monitoring of alert performance to ensure alerts are patient-specific and clinically appropriate.  
Friebe MP, LeGrand JR, Shepherd BE, et al. Appl Clin Inform. 2020;11(5):865-872.
The prescribing of potentially inappropriate medications, particularly among older adults, is an ongoing quality and safety concern. Among adults 65 years and older, this study found that clinical decision support integrated with a new electronic health record system significantly reduced potentially inappropriate medications.   

Nudges are a change in the way choices are presented or information is framed that can have a large, but predictable, impact on medical decision-making, for both patients and providers without actually restricting individual choice. The Nudge Unit at Penn Medicine focuses on a range of different care improvement projects, including safety initiatives, with this framework in mind that are designed to improve workflow, support evidence-based decision-making, and create sustained changes in patient engagement and daily behaviors.1

Kane‐Gill SL, Wong A, Culley CM, et al. J Am Geriatr Soc. 2020;69(2):530-538.
Medication reconciliation and medication regimen reviews can reduce adverse drug events (ADEs) in older adults. This study assessed the impact of a pharmacist-led, patient-centered telemedicine program to manage high-risk medications during transitional and nursing home care. The program included telemedicine-based medication reconciliation at admission and medication regimen reviews throughout the nursing home stay, coupled with clinical decision support. Residents in the program experienced fewer adverse drug events compared to a usual care group. This innovative model has the potential to further reduce medication errors in nursing home residents.