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Problem: Although pharmacists typically enter prescriptions and orders into their computers, specially trained pharmacy technicians or interns perform this function in some settings. When this is the case, the pharmacist later verifies that the order has been entered as prescribed at the same time that he or she is ensuring the appropriateness of the medication and verifying that the proper drug and dose have been prepared. Pharmacists typically check this process by comparing the order, pharmacy label, and final product with each other. As long as the original prescription is included in the checking process, this may seem to be an acceptable way to verify the order entry and the preparation of medications.
However, one major safety concern remains: the checking pharmacist might not know about alerts that were displayed during order entry and that were bypassed. As long as the order was entered as prescribed, the pharmacist might not have been in a position to view computer alerts about a drug interaction, an allergy, a duplicate therapy, an excessive or a subtherapeutic dose, or another contraindication.
Bypassing alerts can often be clinically appropriate, but important warnings can be overridden inappropriately. Bypassing an alert appears to be a rather common practice, especially if the viewer of the information does not value the significance of the alert. The alert systems used during order entry are often quite sensitive so that users do not miss any critical information. However, this sensitivity comes at a cost: frequent false alarms or warnings that might not be clinically significant. Pharmacists can usually cite many examples of these false alarms.
Besides being a nuisance, frequent false alarms can lead to alert fatigue and complacency—or the “cry wolf” syndrome.1 Individual quirks in some pharmacy systems also contribute to missed alerts—conditions that should have triggered an alert but did not. Thus, general annoyance and mistrust in the alert system could be one reason why it may seem acceptable to not worry about the alerts that pharmacy technicians or interns may choose to ignore.
Safe Practice Recommendations: The problem of missing an alert is twofold: the occurrence of false alarms and the pharmacist’s inability to view and assess alerts that might have been bypassed during order entry. Although there are no silver bullets that can solve either problem quickly and effectively, a few suggestions might improve these valuable but imperfect alert systems.
The reports described in this column were received through the ISMP Medication Errors Reporting Program (MERP). Errors, close calls, or hazardous conditions may be reported on the ISMP Web site (www.ismp.org) or communicated directly to ISMP by calling 1-800-FAIL-SAFE or via e-mail at ismpinfo.org.