Appropriateness of commercially available and partially customized medication dosing alerts among pediatric patients

Abstract

Objectives: To evaluate dosing alert appropriateness, categorize orders with alerts, and compare the appropriateness of alerts due to customized and non-customized dose ranges at a pediatric hospital.

Methods: This was a retrospective analysis of medication orders causing dosing alerts. Orders for outpatient prescriptions, patients ≥18 years of age, and research protocols were excluded. Patient medical records were reviewed and ordered doses compared with a widely used pediatric reference (Lexi-Comp) and institutional recommendations. The alerted orders were categorized and the occurrence of appropriate alerts was compared.

Results: There were 47 181 inpatient orders during the studied period; 1935 orders caused 3774 dosing alerts for 369 medications in 573 patients (median age 6.1 years). All alerted orders had an alert overridden by the prescriber. The majority (86.2%) of alerted orders inappropriately caused alerts; 58.0% were justifiable doses and 28.2% were within Lexi-Comp. However, 13.8% of alerted orders appropriately caused alerts; 8.0% were incorrect doses and 5.8% had no dosing recommendations available. Appropriately alerted orders occurred in 19.7% of alerted orders due to customized ranges compared to 12.8% due to non-customized ranges (p=0.002). Preterm and term neonates, infants, and children (2-5 years) had higher proportions of inappropriate alerts compared to appropriate alerts (all p<0.01).

Conclusions: The vast majority of dosing alerts were presented to practitioners inappropriately, potentially contributing to alert fatigue. Appropriate alerts occurred more often when alerts were due to customized ranges. Advances in dosing alerts should aim to provide accurate and clinically relevant alerts that minimize excessive inappropriate alerting. Medications requiring dosing adjustments based on clinical parameters must be taken into account when designing and evaluating dosing alerts.

Keywords: Administration and dosage; Clinical decision support system; Medical order entry systems; Medication errors; Pediatrics; Prescriptions.

Figure 1

Categorization of medication orders.

Figure 2

Proportion of alerted order types due to customized and non-customized ranges. ^aχ² test for differences in distribution. ^bχ² test for alerted order type versus all other types for customized and non-customized ranges.