Overrides of medication-related clinical decision support alerts in outpatients¶
Nanji, K. C., Slight, S. P., Seger, D. L., Cho, I., Fiskio, J. M., Redden, L. M., Volk, L. A., et al. (2014). Overrides of medication-related clinical decision support alerts in outpatients. Journal of the American Medical Informatics Association, 487-491.
Cited by¶
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Primes¶
- Near-Miss Normalization
- The same structure governs clinical medication safety: a pharmacy's barcode-scan override, used repeatedly to push past a dosage alert without an adverse event, is a near-miss stream whose no-harm record is read as evidence the alerts are over-sensitive; the intervention is to audit override frequency as a margin signal and force review when it climbs, rather than waiting for a harmful dose.
This sourceDocuments high override rates of medication (including dose) alerts and alert fatigue, supporting auditing override frequency as a margin signal rather than waiting for a harmful administration.
- The same structure governs clinical medication safety: a pharmacy's barcode-scan override, used repeatedly to push past a dosage alert without an adverse event, is a near-miss stream whose no-harm record is read as evidence the alerts are over-sensitive; the intervention is to audit override frequency as a margin signal and force review when it climbs, rather than waiting for a harmful dose.
Verification¶
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