Table 5.

Summary of articles related to clin ical decision support systems (n=18).

Focus/Intervention	Allergens	Alert Type	Articles	Clinical Setting	Summary of Findings
Descriptive Study Design (n=11)
Measure of allergy alerts and overrides	Food, drug, environment	Food/drug allergy and intolerance alerts	González-Gregori et al. 2012116	Inpatient	Alerts were mainly caused by drugs (74.4%), followed by foods (12.6%) and materials (4.8%).
	Drug	Drug allergy alerts, drug-drug interaction alerts	Lin et al. (2008)127	Inpatient	Clinicians indicated alerts were overly frequent, with low specificity and high sensitivity. 93% drug alerts were overridden. More drug-drug alerts were overridden (87- 95.1%) compared to drug allergy alerts (81-90.9%).
			Weingart et al. (2009)128	Inpatient; Outpatient
			Carspecken et al. (2013)129	Inpatient; Pediatric hospital
			Bryant et al. (2014)119	Inpatient
			Topaz et al. (2016)117	Inpatient	Alerts containing immune mediated (72.8%) and life-threatening reactions (74.1%) were overridden. Narcotics triggered most drug alerts (48%).
			Wong, A; Seger, DL; Slight, SP, et al. (2018)120	Inpatient, Outpatient	46.0% and 68.8% of definite anaphylaxis drug allergy interaction alerts were overridden in inpatient and outpatient settings respectively. 83.9% of inpatient overrides and 100% of outpatient overrides were appropriate.
		drug-allergy, drug-drug interaction, geriatric and renal alerts	Wong et al. (2017)130	Inpatient; Intensive Care Unit	Between commercial and internally developed EHR, physicians experienced more alerts and overrode more alerts with the commercial EHR. (commercial: n=5,535; legacy: n=1,030).
			Wong et al. (2018)131	Inpatient; Intensive Care Unit	81.6% of alert overrides were appropriate in the intensive care unit. However inappropriate overrides were 6 times more likely to result in an ADE compared to appropriate overridden alerts.
		Opioid allergy alerts	Ariosto, D. (2014)118	Inpatient	At least 89% of opioid allergy alerts that make up almost a third of visible alerts were overridden, Physicians are more likely to override opioid alerts than advanced practice nurses.
			Genco et al. (2016)132	Inpatient; Emergency department	34.6% of visible alerts are opioid alerts. Of these alerts, 96.3% were overridden.
Interventional Study Design (n=7)
Create Clinical Decision Support	Radiocontrast Media Agents	Premedication Alerts	Bae et al. (2013)122	Inpatient	There was a significant increase in premedication rates; however, only Bae et al. noticed a significant reduction in breakthrough reactions.
			Benson et al. (2017)123
	Drug	Drug-gene interaction alerts	Dolin et al. (2018)124	NA	With the use clinical decision support and pharmacogenetic sequencing data, genomics-EHR integration can lead to drug-gene interaction alerts.
	NA	NA	Garabedian et al. (2019)133	Outpatient	Redesigning CPOE structure to allow physicians to enter the indication, or reason for medication first, before prescribing will improve usability and user satisfaction while minimizing medication error.
Modified Alerting Rules	B-lactam antibiotics	B-lactam alerts	Macy et al. (2021)125	Inpatient, Outpatient	Elimination of cephalosporin alerts increased cephalosporin use, decreased 2nd line of antibiotic treatment without significantly increasing anaphylaxis
			Buffone et al. (2021)126	Inpatient	7.7% patients were alerted for a B-lactam prescription while 92.3% patients were no longer alerted under the adjusted rules when prescribed a B-lactam antibiotic with a different side chain. They did not report any incidence of anaphylaxis.
Evaluation Tool for Clinical Decision Support		Therapeutic Duplication, Drug-Dose (single and daily), Drug-Allergy, Drug-Route, Drug-Drug, Drug-Diagnosis, Drug-Age, Drug-Labs, Drug-Renal, Monitoring, Nuisance Orders	Cho et al. (2015)121	NA	Using the Leapfrog CPOE evaluation tool, errors were captured in Therapeutic Duplication and Drug-Drug Interaction alerts, mainly.

Abbreviations: CPOE, computerized provider order entry