Human Factors Considerations for Contraindication AlertsHeleen van der Sijs, Imtiaaz Baboe, Shobha Phansalkar

Heleen van der Sijs, PharmD PhDClinical pharmacist, Erasmus Medical Center Rotterdam

Medinfo, Copenhagen, August 2013

Alert fatigue

Mental state that is the result of Alerts consuming too much time and mental energyWhich can cause relevant alerts to be unjustifiably overridden along with clinically irrelevant ones

Ignoring alertsMisinterpretation of alertsWrong selection of handling options

Heleen van der Sijs. Drug Safety Alerting in Computerized Physician Order Entry. Unraveling and Counteracting Alert Fatigue. PhD thesis Rotterdam University. www.repub.eur.nl/res/pub/16936

Counteracting alert fatigueSpecificityPatient-tailored (relevant) alerts, preventing irrelevant alerts

TrainingTeaching how to understand and value alerts

UsabilityAttracting attention: color, visibility, signal wordsFacilitating handling: corrective actions

Human Factors in AlertingI-MeDeSA: Instrument Medication-Related Decision Support Alerts

Quantitative instrument DDI alerting 9 human factors principles, 26 itemsPlacement, visibility, prioritization, colorTextual informationProximity task components, corrective actionsLearnability and confusibility, alarm philosophy

Phansalkar S et al. A review of human factors principles for the design and implementation of medication safety alerts in clinical information systems. J Am Med Inform 2010;17:493-501Zachariah M et al. Development and preliminary evidence for the validity of an instrument assessing implementation of human-factors prinicples in medication-related decision-support systems I-MeDeSA. J Am Med Inform Assoc 2011;18:Suppl 1:i62-72

Contraindications (CIs)Condition of a patient that makes administration of a drugundesirable or dangerousPatient morbidity (epilepsy, diabetes)Patient status (pregnancy, lactation)Allergy or intoleranceDrug-disease alerts, drug-allergy alerts

CI alerts dependent on medication orders + patient characteristicsSeverity level, text messages importantQuantitative human-factors instrument lacking

Research questionsCan the DDI-instrument be used to some extent to CIs?

Which other (drug safety alert) human factors principles apply to CIs?

How should human factors principles for CIs be operationalized?Test cases

Is it feasible to test design quality of CI alerting with this test?

Test items

Test items

Dutch Drug Database G-StandardAll licensed drugs: logistical and safety informationIncluded in pharmacy software, CPOEs for hospitals, GPs Professional standardMonthly update

CI mentioned in the literature Really a CI? Action required?Yes/yes CI alert in CPOEYes/no CI no alertNo/no CI no alert

Severity levels and test drugsCombination productCross-sensitivity

Pregnancy Risk CategoryDrugAction required?Severity levelXRibavirinYesHighDDoxycyclinYesMediumCMetoprololYesLowB3AciclovirYesB2AllopurinolNoB1RabeprazolYesAClindamycinNoAllergyDrugAction required?Severity LevelAmoxicillin CoamoxiclavYesDependent on entered patient symptoms Metoprolol MetoprololYesPenicillin CefuroximYes

TestEnter CI pregnancy (4 months)Trimester can be entered (1)No question on trimester or estimated end date (0)Prescribe ribavirin capsule 200mg QID An CI alert is generated (1) No alert is shown (0)When in the prescribing process the alert is generated?Directly after selecting the drug (1)After prescribing the dose (0)At order completion (0)

Contraindication alertOrder completeInterruptive Screen overlapSeverity Color WordingHandling OK

Results30 items, 10 human factors principles21 items as is5 items slightly modified4 items new (false alarms, alarm philosophy)

1 CPOE: Medicatie/EVS 3 independent ratersScores 0.00 (false alarms not filtered out) 0.89 (visibility)Inter-rater variability =0.540 (moderate agreement)

DiscussionFalse alarmsPregnancy risk category A and B2 (yes/no CI) shown in CPOE Trimester not encoded in G-standard

AllergiesNot possible to enter severity level in CPOESeverity not distinguishable (color, prioritization)

Interrater-variability: moderate agreement Raters no experience in human factors principles

ConclusionNew instrument derived to large extent from I-MeDeSA for DDIs

False alarms is extra human factors principle to be included

Drugs contraindicated in pregnancy and allergy adequate for testing

Feasible to test design quality of CI alerting

Thank you for your attention!Questions?

Heleen van der Sijs, PharmD PhDErasmus MC, Rotterdam, Netherlandsi.vandersijs@erasmusmc.nl

http://repub.eur.nl/res/pub/16936/

*Human Factors Engineering: using human capabilities and limitations for the design of products, systems, processes etc*