Overriding of Drug Safety Alerts in Computerized Physician Order Entry

TLDR

Many CPOE systems include drug safety alerts, yet these alerts often suffer from low specificity, low sensitivity, unclear content, workflow disruptions, and unsafe handling, leading to physician failures such as ignoring or misinterpreting alerts, and studies on the cognitive processes underlying alert overriding are lacking. The study reviews literature on physician responses to drug safety alerts, interprets findings through Reason’s accident causation framework, and argues for distinguishing appropriate from useful alerts while targeting software and organizational error‑producing conditions to improve patient safety. The authors conducted a systematic review of 17 papers, applying Reason’s framework to analyze physician responses to drug safety alerts. Clinicians override drug safety alerts in 49%–96% of cases, and while overrides are often justified, adverse drug events resulting from overrides are not always preventable.

Abstract

Many computerized physician order entry (CPOE) systems have integrated drug safety alerts. The authors reviewed the literature on physician response to drug safety alerts and interpreted the results using Reason's framework of accident causation. In total, 17 papers met the inclusion criteria. Drug safety alerts are overridden by clinicians in 49% to 96% of cases. Alert overriding may often be justified and adverse drug events due to overridden alerts are not always preventable. A distinction between appropriate and useful alerts should be made. The alerting system may contain error-producing conditions like low specificity, low sensitivity, unclear information content, unnecessary workflow disruptions, and unsafe and inefficient handling. These may result in active failures of the physician, like ignoring alerts, misinterpretation, and incorrect handling. Efforts to improve patient safety by increasing correct handling of drug safety alerts should focus on the error-producing conditions in software and organization. Studies on cognitive processes playing a role in overriding drug safety alerts are lacking.