Prescribing alert “fatigue”

DESIGNERS of healthcare systems are continually introducing new ways to support clinicians in making correct diagnostic, treatment and prescribing decisions. Many involve digital alerts whether as part of remote monitoring device feedback systems, automated triage or when prescribing new drugs where a patient has a known allergy, current prescription or a condition for which a proposed medicine is contraindicated.

Such innovations are designed to assist the clinician – and improve patient safety outcomes – but the result can sometimes be “information overload” in busy healthcare environments where clinicians are already struggling to keep up with demand. Here we will examine risks associated with prescribing alerts.

A GMC-funded study in 2012 reported that around one in 13 prescribing errors are associated with contraindications or hazardous drug interactions and this is continually replicated in our own ongoing analysis of prescribing-related negligence claims at MDDUS.

Prescribers can be confronted with multiple warnings from patient management systems about drug interactions – some of them regarding potentially harmful combinations – each time they commence a new medication. Clinical judgement is required to act upon, override or ignore these alerts. In some situations a patient may have competing comorbidities and there will be no alternative to prescribing a medicine which would otherwise be contraindicated, in which case the clinician will take the alert into account and monitor the patient closely for adverse effects.

Certainly it is most logical for a clinician to take notice and act on alerts within the system at the point of prescribing. However, when our risk advisory team are discussing prescribing risk in a training environment, many clinicians admit to feelings of "alert fatigue", and confirm that reading and responding to these can be a challenge.

The GMC is clear that doctors "must make good use of the resources available", and utilising a combination of resources is often advisable when prescribing new medicines. Although the BNF can take more time, the GMC states: "You must be familiar with the guidance in the British National Formulary (BNF) and British National Formulary for Children (BNFC), which contain essential information to help you prescribe, monitor, supply, and administer medicines".

In addition the GMC says: "If you are unsure about interactions or other aspects of prescribing and medicines management you should seek advice from experienced colleagues, including pharmacists, prescribing advisers and clinical pharmacologists".

Up-to-date and accurate clinical coding and a full patient prescribing record are crucial to ensure that alerts prompted by the system are relevant. Documenting hospital-prescribed medicines (e.g. chemotherapy) or over-the-counter medications taken by patients (e.g. antihistamines or low-dose aspirin) in the medical record will avoid serious interactions being missed.

In regard to this, GMC guidance states that: "you must check that the care or treatment you provide for each patient is compatible with any other treatments the patient is receiving, including (where possible) self-prescribed over-the-counter medications".

On a final note, it is less common now for prescribers to delegate to non-clinical staff the task of adding new drugs to the records and certainly this is something to be avoided. Non-clinical staff members are also likely to override alerts as they will assume the clinician has taken these into consideration before deciding to commence a medication.

ACTIONS

• Ensure systems are in place to confirm that the clinical history and prescribing record of your patient are accurate and up to date.
• Ensure that medications prescribed by hospital or taken over the counter by the patient are documented within the primary care records.
• Check other sources of information (if an alert is not detailed enough) for drug combination outcomes, including frequency and severity of interactions – e.g. a current BNF.
• Be sure to document that the patient has been fully informed when a contraindicated medicine has been prescribed – including red flags and any special monitoring required.
• Ensure robust systems are in place to follow up patient prescribing.

Next month’s Risk Alert will look at the risks associated with the management of digital alerts from remote monitoring devices.

Liz Price is senior risk adviser at MDDUS