The absence of a drug–disease interaction alert leads to a child's death.
Approach to Improving Safety
Setting of Care
The disabling of alerts due to alarm fatigue can hinder the ability of a health information system to warn prescribers and pharmacists of potentially harmful drug–disease combinations. This newsletter article describes an incident in which a patient died when health information technology systems failed to alert the physician and pharmacist regarding a drug–disease interaction. Recommendations to avoid risks include evaluating drug information databases, adding comorbid conditions into electronic health records, and reducing provider overreliance on alerts.