Background: Clinical decision support systems (CDSS) can enhance patient safety and reduce medication errors by giving physicians alerts while dispensing medications. Physicians inappropriately override these alerts for various reasons, which can possibly lead to medication errors and impact patient safety. Objective: To assess the appropriateness of overridden major medication-related alerts, to investigate the reasons behind inappropriate overriding, and to evaluate if medication errors occur in inappropriately overridden alerts. Methods: A mixed-methods study. Quantitative: Retrospective observation to evaluate the appropriateness of major drug-dose related alert overrides. A simple random sample was taken from appropriate and inappropriate overrides and reviewed for medication errors. Qualitative: Semi-Structured Interviews were conducted with ten consultant physicians from various specialties. Interviews were transcribed and coded inductively then analyzed using Thematic Content Analysis. Results: Out of 1087 alert overrides that were evaluated for appropriateness, 738 were inappropriately overridden (67.89%). In a sample of 283 inappropriate and 92 appropriate overrides; the resulted medication errors were 7 and 0, respectively. Qualitative analysis resulted in three emergent themes; Judgement, Experience & Guidelines, CDSS Issues & Limitations, Physician Behavior & Safety. Conclusion: The majority of alerts were found to be inappropriately overridden. This can be attributed to physician reliance on their clinical knowledge and medication databases, having the pharmacists checks, and alert fatigue. CDSS alerts can be improved by making them more prominent and suppressing or descaling unnecessary alerts. The drop-down justification list can be enhanced by adding free text options and relating recommended dosing to disease or specialty.
Key words: CDSS, clinical decision support systems, alert override, medication error, medical error, alert fatigue, medication alert.
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