These 2 cases add to the growing literature detailing UACs of CDSSs.
While they have some similarities to cases in previous reports, the lack of knowledge of an external pharmacy system and a change in the chemistry instrumentation in the clinical laboratory leading to CDSS malfunction have not been previously reported.
While focusing on medication CPOE, a white paper that reviewed 10 order entry systems across 6 health care organizations found issues related to CDSS monitoring.
None of the sites could provide simple reports on alert appropriateness, alert frequency, override frequency, or override reasons.
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.It should also be noted that the interfaces from these 2 systems to the EHR (and hence to the CDSS) were also working as designed.This is in contrast to some reports of UACs related to interface errors.These 2 cases of UAC relate to a CDSS that was deployed as part of an EHR implementation in a large integrated delivery system.This CDSS is a commercial knowledge-based system that provides active, patient-specific, synchronous, on-screen alerts at the point of care and is fully integrated with the commercial EHR.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.This team (manager and alert builders) should include members in specific clinical specialties with deep knowledge of these external systems.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 alert triggered from an ED diagnosis of AMI or a troponin level 0.5.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.