J Am Med Inform Assoc 18:251-258 doi:10.1136/amiajnl-2011-000129
  • Research and application

Characteristics and effects of nurse dosing over-rides on computer-based intensive insulin therapy protocol performance

  1. Cynthia S Gadd1
  1. 1Department of Biomedical Informatics, Vanderbilt University School of Medicine, Nashville, Tennessee, USA
  2. 2Division of Quality and Medical Informatics, Weill Cornell Medical College, New York, USA
  3. 3Division of Trauma and Surgical Critical Care, Vanderbilt University School of Medicine, Nashville, Tennessee, USA
  4. 4Department of Biostatistics, University of Kansas School of Medicine, Kansas City, Kansas, USA
  1. Correspondence to Dr Thomas R Campion Jr, 402 East 67th Street, Second Floor, New York, NY 10065, USA; thc2015{at}
  • Received 21 January 2010
  • Accepted 29 January 2011
  • Published Online First 14 March 2011


Objective To determine characteristics and effects of nurse dosing over-rides of a clinical decision support system (CDSS) for intensive insulin therapy (IIT) in critical care units.

Design Retrospective analysis of patient database records and ethnographic study of nurses using IIT CDSS.

Measurements The authors determined the frequency, direction—greater than recommended (GTR) and less than recommended (LTR)— and magnitude of over-rides, and then compared recommended and over-ride doses' blood glucose (BG) variability and insulin resistance, two measures of IIT CDSS associated with mortality. The authors hypothesized that rates of hypoglycemia and hyperglycemia would be greater for recommended than over-ride doses. Finally, the authors observed and interviewed nurse users.

Results 5.1% (9075) of 179 452 IIT CDSS doses were over-rides. 83.4% of over-ride doses were LTR, and 45.5% of these were ≥50% lower than recommended. In contrast, 78.9% of GTR doses were ≤25% higher than recommended. When recommended doses were administered, the rate of hypoglycemia was higher than the rate for GTR (p=0.257) and LTR (p=0.033) doses. When recommended doses were administered, the rate of hyperglycemia was lower than the rate for GTR (p=0.003) and LTR (p<0.001) doses. Estimates of patients' insulin requirements were higher for LTR doses than recommended and GTR doses. Nurses reported trusting IIT CDSS overall but appeared concerned about recommendations when administering LTR doses.

Conclusion When over-riding IIT CDSS recommendations, nurses overwhelmingly administered LTR doses, which emphasized prevention of hypoglycemia but interfered with hyperglycemia control, especially when BG was >150 mg/dl. Nurses appeared to consider the amount of a recommended insulin dose, not a patient's trend of insulin resistance, when administering LTR doses overall. Over-rides affected IIT CDSS protocol performance.


  • Funding TRC received support from National Library of Medicine Training Grant NLM T15 007450-07.

  • Ethics approval Ethics approval provided by Vanderbilt University Institutional Review Board.

  • Provenance and peer review Not commissioned; externally peer reviewed.

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