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How to Design Computerized Alerts to Ensure Safe Prescribing Practices

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Abstract:

Background: Medication errors and preventable adverse drug events are common, and about half of medication errors occur during medication ordering. This study was designed to develop and evaluate medication safety alerts and processes for educating prescribers about the alerts.

Methods: At Kaiser Permanente Northwest, a group-model health maintenance organization where prescribers have used computerized order entry since 1996, qualitative interviews were conducted with 20 primary care prescribers.

Results: Prescribers considered alerts helpful for providing prescribing and preventive health information. More than half the interviewees stated that it would be unwise to let clinicians control or avoid safety alerts. Common frustrations were (1) being delayed by the alert, (2) having difficulty interpreting the alert, and (3) receiving the same alert repeatedly. Most prescribers preferred small-group educational sessions tied to existing meetings and having local physicians conduct education sessions.

Discussion: The findings were used to design a strategy for introducing and promoting the interventions, modifying the alert text and tools, and focusing the education on how clinicians could use the alerts effectively.

Document Type: Research Article

Publication date: 2004-11-01

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  • The Joint Commission Journal on Quality and Patient Safety will be published by Elsevier beginning in 2017! For readers who receive access to the journal through their institutions, the journal can now be found on ScienceDirect (http://www.sciencedirect.com/science/journal/15537250). For librarians looking to subscribe to the journal for their institutions please contact your Elsevier Account Manager or visit www.myelsevier.com for more information. All other readers, please visit http://www.jointcommissionjournal.com/ to subscribe to the journal or to claim your access for an existing subscription.
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