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Purpose: Dosing range alerts are frequently used in pediatric institutions. Nationwide Children’s Hospital’s (NCH) dosing alert system combines rule logic created by First Databank (FDB) with NCH customization. Detailed analysis of alert appropriateness is lacking. The aims of this study were to characterize and evaluate dosing alerts occurring at NCH.
Methods: This was a retrospective analysis of practitioner viewed dosing alerts during July 2011. Orders were excluded if they were outpatient or discharge prescriptions, for age ≥18 years, or part of a research protocol. For each order, patient charts were reviewed and doses were compared with Lexicomp® and hospital practices. Rule logic for each alert was analyzed. A 95% binomial confidence interval was used to describe the number of alerts for orders outside reference ranges.
Results: Of 1936 orders that led to alerts for 701 patients (mean age 7.1 years), 58% of orders were outside of Lexicomp®, either due to different hospital practice ranges or clinical situations (e.g., titrations and pharmacokinetic adjustments). 28% of orders with alerts were within Lexicomp® ranges, but the rule logic was unable to describe the dosing. 6% of orders with alerts used extrapolated pediatric dosing due to knowledge deficiencies. 8%(155) of orders with alerts were prescribed outside of all reference ranges. FDB rule logic alerted 122 of these orders and all 155 orders were alerted by FDB rule logic with NCH customization (CI 71-85%,p< 0.001). All 155 orders had alerts overridden by at least one practitioner and 43%(66) of the medications were administered.
Conclusion: Dosing alerts designed by FDB alerted practitioners when abnormal dosing occurred and were enhanced by NCH customization, contributing to dosing error prevention. However, many alerts for orders outside of reference ranges were overridden and doses administered. Further, 86% of alerts warned practitioners for doses within Lexicomp® or due to clinical situations.