. "6 Action Agenda for the Pharmaceutical, Medical Device, and Health Information Technology Industries ." Preventing Medication Errors: Quality Chasm Series. Washington, DC: The National Academies Press, 2007.
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Preventing Medication Errors
TABLE 6-2 Sample of Alert Types, Most Common Occurrences, and Most Common Reasons for Alert Override
Alert Type
Most Common Occurrences of Highest Alerts
Most Common Reasons for Alert Override
Therapeutic duplication
Analgesic (29%)
Psychiatric (26%)
Gastrointestinal (19%)
Cardiac (17%)
Endocrine (9%)
Transitioning from one drug to another (42%)
Long-term therapy with combination (21%)
Short-term combination (7%)
Advice from consultant (5%)
Drug–drug interaction
Sildenafil and isorbide mononitrate
Gatifloxacin and levofloxacin
Linezolid and methylphenidate
Clinician would monitor patient (49%)
Patient previously tolerated drug (21%)
Clinician would adjust dose as recommended (14%)
No reasonable alternatives (4%)
Drug– laboratory
Not documented
Clinician would monitor/ manage as recommended (67%)
Most recent laboratory test results available (18%)
Patient on dialysis (11%)
Drug– disease
Hepatic disease contraindications
Seizure disorder contraindications
Coronary artery disease contraindications
Patient previously tolerated drug (56%)
New evidence for use (22%)
Advice from consultant
No reasonable alternative (11%)
Drug– pregnancy
Isotretinoin
Leflunomide
Misprostol
Patient is not pregnant (93%)
Advice from consultant (1%)
No reasonable alternative (1%)
Patient previously tolerated drug (1%)
Short-term use (1%)
SOURCE: Shah et al., 2006
imply that known dangerous drug interactions or contraindications will change; instead, they reflect a recognition that in some cases, certain clinical preferences should take precedence. Thus, ranking of alerts according to all three dimensions—severity, frequency, and clinical importance—is necessary.
Intelligent Prompting
Technology that could use intelligent or intuitive mechanisms to prompt alerts would require the application of additional parameters beyond sever-
