County Durham and Darlington NHS Foundation Trust
NHS / Health Body
Action Planned
The Trust is convening a multi-disciplinary group, led by the Chief Pharmacist, to review all Major (level 2) drug-to-drug interactions to determine if any are appropriate to activate a prescriber alert within their electronic patient record system. (AI summary)
View full response
Dear Mr Thompson, Re: Gillian Peacock We are writing in response to your request for the Trust to take action in relation to your concerns following the inquest held on 5th June 2024. Your concern was that current processes mean that important medical information being recorded in a patient's notes is not accessible in such a way that clinicians can see, and if necessary act, on it. You suggested that this was in part due to the way the entries are displayed in the records and the 'huge' number of entries that are recorded. The Trust would like to offer its sincere condolences to Gillian’s family for their loss. We take very seriously the concerns which you have raised and have provided a response below. Electronic patient records (EPR) bring with them significant benefits in that notes are legible, structured and individual entries are significantly easier to locate than in paper notes. As you heard at the inquest the pharmacy entry in Mrs Peacocks notes was made on 1st March 2023 and in additon to the documented note was also verbally handed over to the medical team. Figure 1 below shows the entry in the documentation list and Figure 2 shows the detail of the pharmacy entry. Figure 1 – Pharmacy Note in Documentation List
Figure 2 – Detail of Pharmacy Entry in Documentation Whilst the Trust acknowledges the suggestion that some form of alert would have been of benefit we would like to highlight that there needs to be a judicious use of alerts. In one month there are circa 250,000 alerts fired in the EPR. In the period 23 Jun – 24 Jul 2024 44% (109,023 of 247,365) of all alerts fired were related to medications and prescribing.
Figure 3 – Number of Alerts Fired by Day
Figure 4 – Number of Alerts by Category
Alerts in the EPR are referred to as clinical decision support and are a tool that helps clinicians in decision making by generating clinical alerts to supplement their previous knowledge and experience. However a large number of alerts can result in alert fatigue. (2020) define this as: ‘the mental state of alerts consuming too much time and mental energy, which often results in relevant alerts being overridden unjustifiably, along with clinically irrelevant ones. Consequently, clinicians become less responsive to important alerts, which opens the door to medication errors’ There are 4 levels of alerts relating to drug to drug interactions that are imported into Cerner EPR from the Multum drug interactions database: Level 1 Major contraindicated - This interaction poses a major threat to the patient’s health and is the highest severity level. This requires a prescriber to either discontinue the pre-existing, interacting medication order, or override the alert with a documented clinical reason. Level 2 Major - This interaction poses a major threat to the patient’s health and is not recommended. This category includes interactions where additional contraception may be needed, an interval adjustment, dose adjustment or close monitoring is recommended. Level 3 Moderate - The interaction poses a moderate threat to the patient’s health and should be evaluated. Level 4 Minor – This interaction poses a minimal threat to the patient’s health. The EPR at CDDFT has Level 1 alerts activated within the system and includes approximately 11200 different drug-drug interactions. The interaction between digoxin and clarithromycin is classed as a Major (level 2) interaction where additional monitoring or dose adjustment would be appropriate. In line with other organisations utilising this software, level 2 and below interactions are not activated as prescriber alerts within the system due to the risks of alert fatigue described above. If level 2 drug-drug interaction alerts were activated this would include a further 23400 drug-drug interaction combinations. Having taken into consideration your concerns the Trust is convening a multi-disciplinary, cross speciality group led by the Chief Pharmacist to review all Major (level 2) drug to drug interactions to review whether any are appropriate to activate a prescriber alert. Conclusion We trust that the responses detailed in this letter are sufficient to address the concerns you have highlighted. However, please feel free to contact us if you need any additional information or have further queries.
Figure 2 – Detail of Pharmacy Entry in Documentation Whilst the Trust acknowledges the suggestion that some form of alert would have been of benefit we would like to highlight that there needs to be a judicious use of alerts. In one month there are circa 250,000 alerts fired in the EPR. In the period 23 Jun – 24 Jul 2024 44% (109,023 of 247,365) of all alerts fired were related to medications and prescribing.
Figure 3 – Number of Alerts Fired by Day
Figure 4 – Number of Alerts by Category
Alerts in the EPR are referred to as clinical decision support and are a tool that helps clinicians in decision making by generating clinical alerts to supplement their previous knowledge and experience. However a large number of alerts can result in alert fatigue. (2020) define this as: ‘the mental state of alerts consuming too much time and mental energy, which often results in relevant alerts being overridden unjustifiably, along with clinically irrelevant ones. Consequently, clinicians become less responsive to important alerts, which opens the door to medication errors’ There are 4 levels of alerts relating to drug to drug interactions that are imported into Cerner EPR from the Multum drug interactions database: Level 1 Major contraindicated - This interaction poses a major threat to the patient’s health and is the highest severity level. This requires a prescriber to either discontinue the pre-existing, interacting medication order, or override the alert with a documented clinical reason. Level 2 Major - This interaction poses a major threat to the patient’s health and is not recommended. This category includes interactions where additional contraception may be needed, an interval adjustment, dose adjustment or close monitoring is recommended. Level 3 Moderate - The interaction poses a moderate threat to the patient’s health and should be evaluated. Level 4 Minor – This interaction poses a minimal threat to the patient’s health. The EPR at CDDFT has Level 1 alerts activated within the system and includes approximately 11200 different drug-drug interactions. The interaction between digoxin and clarithromycin is classed as a Major (level 2) interaction where additional monitoring or dose adjustment would be appropriate. In line with other organisations utilising this software, level 2 and below interactions are not activated as prescriber alerts within the system due to the risks of alert fatigue described above. If level 2 drug-drug interaction alerts were activated this would include a further 23400 drug-drug interaction combinations. Having taken into consideration your concerns the Trust is convening a multi-disciplinary, cross speciality group led by the Chief Pharmacist to review all Major (level 2) drug to drug interactions to review whether any are appropriate to activate a prescriber alert. Conclusion We trust that the responses detailed in this letter are sufficient to address the concerns you have highlighted. However, please feel free to contact us if you need any additional information or have further queries.