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Cases & Commentaries
- Web M&M
Russ Cucina, MD, MS; April 2005
Thinking that the patient's glycemic control had spontaneously improved (and not realizing that the patient was continuing to receive long-acting insulin injections), a physician discontinues daily glucose checks and insulin sliding scale orders. Four days later, the patient is found unresponsive and hypoglycemic.
Journal Article > Study
Evaluation of harm associated with high dose-range clinical decision support overrides in the intensive care unit.
Wong A, Rehr C, Seger DL, et al. Drug Saf. 2019;42:573-579.
Although clinical decision support is intended to improve safety, decision support alerts often result in alert fatigue and overrides. This prospective observational study examined overrides for exceeding the maximum dose of a medication in the intensive care unit. Researchers determined that insulin was the most frequent medication for which a maximum dosage alert was overridden. In almost 90% of cases, the overrides were deemed clinically appropriate. The authors conclude that more intelligent clinical decision support for medication dosing is needed to balance safety with alert fatigue in the intensive care unit. A past PSNet perspective discussed the challenges of implementing effective medication decision support systems.