Sunday, April 8, 2018

Avoiding Drug Interactions and Side Effects - Be Warned!


Eons ago, there was a television show where a non-human character would yell out, ‘Warning’, Warning’, when he sensed imminent danger.   The series was called Lost in Space where we were entertained by a set of quirky characters on a cheesy set.  We loved that stuff.  It’s hard to imagine today’s millennials and younger folks being transfixed, as we were, with the deep television dramas of our day.  Who could match the subtle allegory and nuance of shows such as Green Acres or Gomer Pyle?  Some superficial viewers regarded The Andy Griffith Show as a homespun, idyllic view of small town America.  In truth it was a biting satire on the excesses and abuses of law enforcement in the 1960’s.


Robot and Dr. Smith


I am overwhelmed with the warnings that I receive in my work and in my life.  It seems that warnings, caveats and disclaimers are so omnipresent that they have lost their impact.  As I write this, I am seated in McDonalds, sipping a cold beverage that does not quite qualify as a nutritive elixir.  Had I chosen a steaming hot ‘cup of joe’, I’m quite certain that the beverage’s container would warn me that it contains a hot beverage.  Such a warning, of course, is of great benefit to the consumer, who would behave entirely differently equipped with the knowledge that his hot coffee is actually hot. 

With some regularity, when I prescribe a medication using our office’s beloved electronic medical record (EMR), a red warning flashes indicating that there is a potentially severe interaction with one of the patient’s current medications.  The intensity of the warning would suggest that I was prescribing cyanide or rat poison.   Our EMR allows me to bypass the warning and prescribe anyway, leaving this action memorialized in the EMR and available to plaintiff attorneys who might be in a position to query me on this decision, should an adverse medical event ensue. 

Now, I take these warnings seriously and would never place a patient at risk, unless the medical circumstances justified it, and the patient was properly informed.  My point is that many of these electronic warnings are hyperbolic, if not spurious.  Many times when I call a pharmacist – a human drug professional – in the presence of the patient, I am advised that there is no material risk.  In fact, the last time I did this just a few weeks ago, the pharmacist assured me that there was NO risk of an interaction.  I always document these conversations in the record and hope that the truth would set me free, if necessary. 

I cannot explain why the EMR’s software is set so sensitively.  I suppose I could investigate raising the threshold for issuing an apocalyptic warning, but then I might miss some actual legitimate warnings.

Do you think that all of the warnings we read, hear and trip over are issued to protect us or the companies and organizations that issue them?

5 comments:

rotator said...

And now coffee is known to the state of california to be a carcinogen and
hazard to humans....

Michael Kirsch, M.D. said...

@rotator, I have the Krazy Koffee issue on my list for a future post.

Jean H said...

Years ago I worked for an organization responsible for developing the warnings in the computerized EHR. I was responsible for researching primary medical literature to identifity the basis of the warnings and translate the warnings to the information contained in the database. I have also been a dispensing pharmacist who recieved a daily barage of warnings. Although I am sure things have progressed since I worked on developing the warnings, I doubt that some of the issues of translating risk identified by studies and case reports to prospective Drug Utilization Review (DUR) alerts have been improved.
Have you ever tried to communicate with the developer of those warnings to discern exactly what the issue is and how the warning applies to your situation? I have.
My time would have been better spent talking to a brick. There is no useful feedback or dialogue.
Our insurance carrier sent my husband a letter suggesting he talk with his physician about adding a medication based on his risk profile. I called the phone number on the letter and asked to speak with the physician who signed the letter. I did not feel based on what I knew that the situation applied to him. I still have not gotten an answer from the insurance carrier. My husband was upset, I wasted a lot of time and the letter wasted our time. No clinical person called me back. I spoke with a nurse who could not explain the basis of the letter. She could not refer me to anyone else.
My point, until there is some meaningful feedback and assessment of the utility of the warnings and an effort to eliminate unneeded warnings we will continue to waste time and become numb to all the alerts.

DrBones said...

"The Computer Made Me Do It"

Will this become a valid defense, not that the computer programmers have shifted the blame to us???

Michael Kirsch, M.D. said...

@DrBones, do you think this defense will persuade a judge and jury?

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