Document Type
Article
Abstract
Objectives: Clinical decision support is a form of health information technology utilized by electronic health records (EHRs) to reduce prescribing errors. The challenge of incorporating clinical decision support into medication workflows is balancing alert fatigue with clinical appropriateness. At our 777-bed tertiary cancer center, one form of interruptive clinical decision support is critical dose warnings that appear when the ordered dose deviates by a defined threshold from the maximum dose. Our tertiary cancer center relies on a third-party data vendor to provide maximum dose limits that are integrated into the EHR medication ordering process. At the time of project initiation, only critical single dose warnings were visible, with a deviation threshold of 500%; therefore, end users did not see critical daily dose warnings.
Materials and Methods: At our cancer center, critical daily dose warnings with deviation thresholds ≥ 500% were evaluated for clinical appropriateness from October 31, 2024, to March 31, 2025. A clinically appropriate warning was defined as one that identified a dose unsupported by published literature after considering patient-specific and clinical factors. The project aim was to reduce clinically inappropriate critical daily dose warnings by 10% by June 2026. During the pre-intervention period, there were 1926 critical daily dose warnings ≥ 500% deviation threshold. The top 10 medications accounted for 74% (n = 1432) of these warnings, all of which were determined to be clinically inappropriate. Interventions included implementing a 500% critical daily dose deviation threshold, establishing medication-specific exception thresholds based on clinical appropriateness, and implementing a custom maximum daily dose for 3 medications from the top 10 medication list.
Results: Five months after the intervention, critical daily dose warnings represented 55% (n = 454) of all critical dose warnings. The top 10 medications accounted for 30% (n = 134) of these warnings. Clinically inappropriate warnings for these medications decreased from 1432 to 35, a 74% reduction. Critical daily dose warnings decreased from 0.320 to 0.085 warnings per 1000 orders, while overall critical dose warnings decreased from 0.390 to 0.150 per 1000 orders.
Conclusions: The intervention achieved the study aim, resulting in a 74% reduction in critical daily dose warnings among the top 10 contributing medications. This project highlights the importance of continually refining clinical decision support tools to improve workflow efficiency and reduce alert fatigue for ordering providers. It also emphasizes that assessment of clinical appropriateness must remain an ongoing process as new medications, evidence, and clinical practices continue to evolve.
DOI
https://doi.org/10.52519/ACEQI.26.2.2.a9
Creative Commons License
This work is licensed under a Creative Commons Attribution-NonCommercial-Share Alike 4.0 International License.
Recommended Citation
Erwin M, Eslaminejad S, Perez D, Mathew J. Critical Daily Dose Warning Optimization in an Electronic Health Record at a Tertiary Cancer Center. Advances in Cancer Education and Quality Improvement. 2026; 2(2). doi: https://doi.org/10.52519/ACEQI.26.2.2.a9.
