Decision Support Systems Research Papers
Upon review of the logic of the alert and an interview with the CDSS alert builder, the logic did not take into account that alpha/beta blockers have beta-blocker activity.The builder had built the alert based on medication categories and had assumed that our third-party pharmacy database vendor had categorized alpha/beta blockers into both the alpha-blocker category and the beta-blocker category.The investigators also found that alerts were inconsistent and varied by user role, the screen used to order medications, whether a medication was ordered by brand or generic name, and site of care (inpatient vs outpatient).The investigators also found that most sites edited the alert rules they obtained from third-party pharmacy database vendors, thus potentially introducing errors into the CDSS.Compared to the literature representing the effectiveness of CDSSs, the literature on the UACs of CDSSs is small.Detailed here are 2 cases describing types of CDSS adverse events related to external systems that have not been previously reported.In the first case, lack of knowledge of data categorization in an external pharmacy system produced a UAC; in the second case, the change of a clinical laboratory instrument produced the UAC. These systems are dynamic and may have changes in hardware, software, vendors, or processes. These cases point to the need for the CDSS team to be familiar with these external systems.
While the alert appeared to be working well for a couple of years after it was released, we soon received reports from ED physicians that it was overfiring, especially on patients with undetectable troponins, and that some patients might be receiving aspirin unnecessarily.
Many institutions have implemented clinical decision support systems (CDSSs).
While CDSS research papers have focused on benefits of these systems, there is a smaller body of literature showing that CDSSs may also produce unintended adverse consequences (UACs).
With the rapid spread of health information technology has come the rapid deployment of clinical decision support systems (CDSSs).
Using current patient-level data, CDSSs can provide patient-specific recommendations to providers at the point of care.
At discharge, the discharging resident-in-training acted on a CDSS alert to start a beta blocker in patients with a diagnosis of AMI who did not have one in their discharge medication list. Two days later, this patient presented to the emergency department (ED) with bradycardia and hypotension.