Which orders are NOT checked? (Development of these interventions is in progress)
When you write a new medication order, Order Entry checks for potential level 1 and level 2 interactions between the new drug and any existing medication orders. For ambulatory locations only, orders for chemotherapy medications only are checked against the medications list in the Longitudinal Medical Record (LMR). The check for drug-drug interactions is independent of duplicates and allergies interventions.
Level 1 interactions, all inpatient orders and ambulatory non-chemo orders Level 1 interactions are potentially extremely detrimental or fatal to the patient. You can only order one of the two medications in question, either by canceling the new order or discontinuing the existing order. Inpatient orders that you opt to discontinue at the DDI prompt are discontinued automatically. See Responding to Level 1 DDI Warnings.
Level 1 interactions, ambulatory chemo with LMR medications Level 1 interactions are potentially extremely detrimental or fatal to the patient. For ambulatory orders for chemotherapy only, which interact with a chemo on the patient's LMR active medication list, the chemo medication shown cannot be ordered. To include the medication in the ambulatory chemo orders, you must continue past the DDI warning, then cancel the chemo orders. Next, discontinue the interacting medication in the LMR. See Discontinuing Medication Orders in the LMR. Finally, write the ambulatory chemo orders.
Level 2 interactions indicate potential complications that must be considered in light of the clinical situation. A number of responses is possible, depending on the medications in question. The simplest is to cancel the new order, or discontinue the existing order. For conflicts between ambulatory chemo orders and chemo medications on the patient's LMR, you must discontinue the order in the LMR if you select this option. See Discontinuing Medication Orders in the LMR. Inpatient orders that you opt to discontinue at the DDI prompt are discontinued automatically. If you opt to continue with both, you must select one or more reasons for overriding the warning. For some situations, a checkbox order for relevant therapeutic drug monitoring is also available. The summary views of both orders are flagged with <IOvr>, and the intervention and override are documented in the order details. See Responding to Level 2 DDI Warnings.
Level 3 interactions result in a simple message without requiring additional response. The DDI indications are displayed at the bottom of the order form on the DDI tab. It is also included in the detail of the orders involved, which can be viewed using the Zoom function or on an expanded print copy.
Multiple Level 1 warnings between a new medication and more than one existing med order are presented in separate warning windows. If you cancel the new order, the intervention prompts stop, and any previous selection to D/C an existing order is ignored. To keep the new order, you must discontinue each of the existing orders that invokes the intervention.
Multiple Level 2 warnings between a new medication and more than one existing med order are presented in a single warning window. That is, if a new medication order invokes a Level 2 intervention against more than one existing medication, you must cancel the new order or handle each existing order separately from the single warning window. Often, you will have to scroll down to view every order.
Restoring discontinued orders before signing: Delete the new order that invoked the DDI warning, and the D/C orders written via the related DDI intervention are automatically deleted.
Chemotherapy Regimens and Protocols:
Clinicians who do not have chemotherapy authorization in Order Entry cannot discontinue orders for chemotherapeutic agents.
Medications and chemotherapeutic agents that are required by a standard regimen can be discontinued in response to a DDI warning. You will be prompted to provide a reason for omitting the medication. Usually, the reason text field is pre-filled with "Drug-Drug Interaction". You can add to this as needed.
Medications that are not chemotherapeutic agents that are required by an investigational protocol can be discontinued in response to a DDI warning. You will be prompted to provide a reason for omitting the medication. Usually, the reason text field is pre-filled with "Drug-Drug Interaction". You can add to this as needed.
Chemotherapeutic agents that are required by an investigational protocol cannot be discontinued in response to a DDI warning.
DDIs will trigger even if the dose of the chemo agent(s) involved is set to zero.
Chemotherapy orders in existing protocols may invoke Level 1 or Level 2 DDIs with other medication or chemo orders in that same protocol. Chemo orders in a protocol cannot be discontinued. When a Level 1 DDI exists between two chemo agents in a protocol, it is not possible to order from the protocol.
MGH inpatients, new active med orders including chemotherapeutic agents: New medication orders are checked against other active orders only. See below for situations that do not provide DDI checking.
MGH Pre-Admission, Transfer, Post-Operative, and New Inpatient Chemo (NICO) orders: All medication orders including chemotherapeutic agents in a special orders session are checked against each other when you write or edit an inactive order session. Activation of pre-admit, transfer, or post-op orders automatically inactivates any existing active orders, eliminating most potential DDIs. See below for situations that do not provide DDI checking.
MGH, Dana-Farber, and Faulkner Hospital Ambulatory Chemotherapy: All new medication orders including chemotherapeutic agents are checked against all active medication orders AND all medication orders that are awaiting activation.
Which orders are NOT checked? (Development of these interventions is in progress)In the following situations, take care to check for potential drug-drug interactions:
MGH inpatients, new active med orders added to inactive order session at prompt: If transfer or post-op orders exist when you write new active orders, on signing you are prompted to add the new orders to the transfer or post-op session, or leave the special orders as they are. If you add orders, any DDI related D/C orders will be added as well. However, the inactive orders are not checked against any new orders added this way. If an order that would invoke a DDI warning against the new med exists in the transfer or post-op session only, DDI interventions won't catch it.
MGH New Inpatient Chemo Orders (NICO): New active medication orders are not checked against inactive NICO sessions. NICO activation adds orders to the active record without affecting existing active orders, unlike special orders such as transfers. There is no automatic inactivation to eliminate potential DDIs.