Table 2 Table of interview excerpts

Perceptions of clinical decision support

“The alerts and warnings although frustrating at times are very useful in the flagging of things that you may not have seen or thought of and yeah, just the in-built prescribing for certain drugs for particular dosages, which it suggests, obviously that’s great it makes our life a lot easier, we’re not always looking in the BNF (British National Formulary).” (Individual Interview 9)

“The way I use PICS (Patient Information and Communication System) is quite safe and okay there were some alerts which or the warnings that I ignored but there, I wouldn’t ignore say a red SEWS (Standardised Early Warning Score) score box but I would ignore the thrombosis assessment because the patient is on Enoxaparin.” (Individual interview 3)

“I find that it’s quite overwhelming to log on to the system and suddenly see alert after alert (…) but I’ve had a couple of occasions where I’ve been on call and I’ve had a flash-up of an alert on a patient’s observation and it hasn’t been communicated to me in any way by any of the nursing staff and I’ve been able to go and see that patient and find that actually PICS is alerting me to this patient and actually they are quite unwell and probably should have been seen so once or twice I’ve found it very useful.” ( Individual Interview 4)

“Sometimes you can ignore and sometimes you can accept because sometimes I can’t remember what I was supposed to click (…) because you’re reflecting on what you have to do for the patient.” (Focus group 2)

“Lab alerts and alarms I don’t think are of any relevance whatsoever in my prescribing practice, it doesn’t change the way that I work.” (Focus group 2)

Feedback on performance

“I think that’s the only thing that to be honest I kind of took away which was that I was more conscientious about my prescribing. When I see the levels go sort of high that’s when I sort of started making sure my dosing was correct and that the drug history was correct and that I was looking at interactions and was cautious about allergy status so I was just saying as a whole it flags up to me that you know to be actually a bit more cautious.” (Individual interview 4)

“We crave feedback, to know whether we are good doctors or bad doctors or what we’ve done well or what we’ve done badly, but unfortunately the feedback that we desire and the feedback that we get are very different.” (Focus Group 2)

“Military patients have a set pain protocol which involves (…) prescribing a number of opioids. So every time that I put somebody on this pain protocol, I get a red alert saying ‘multiple opioid drugs prescribed, are sure you want to proceed?’, so I tick yes but obviously then on the dashboard I will get a negative mark if you like.” (Individual Interview 6)

Limits of clinical decision-making

“Sometimes you do override warnings on PICS for different reasons and that is usually not because you’re being blasé about it but it can sometimes be because you’re on ward round and the boss says ‘prescribe this’ and you’ll say ‘do you know about this’ and he says ‘yes continue’. (…) So it’s not your decision.” (Individual Interview 8)

“A lot of the prescribing decisions are [made by the] consultant…like it’s very unusual that a consultant on a ward round will log into his PICS and prescribe the drug.” ( Individual Interview 5)

“Decisions to put patients on drugs isn’t really down to us anyway. I wouldn’t say ‘start a patient on laxatives or painkillers’, but then other than emergency treatment I never really start a patient on drugs by my own means. I will always go through a senior doctor.....So are you looking at the right cohort as to who makes the decisions?” (Individual Interview 3)

Appropriate Accountability

“I think when it comes to alerts there should be accountability i.e. if it’s your patient that you’re looking after it’s useful to have an alert ….. if I see someone that I don’t know the patient then I will press ignore. So there should be accountability, but if someone came to me and said ‘I don’t like how many things you’ve been ignoring’ I would say to them ‘I don’t care it’s really not my concern’.” (Focus Group 1)

“Sometimes I think it pressured me into ticking off things that maybe I shouldn’t have been ticking off, particularly when you’re doing say night cover so (…) every ward you get on to you get flashed up a selection of lab alarms about patients you’ve never met so it’s not really appropriate to be accepting those because you don’t know anything about any of them (…) you don’t really feel like that’s my responsibility and yet at the same time, I’m ignoring lab alerts.” (Individual Interview 2)

“Overnight when I do nights and things flash up and it’s in the relevant directorate (…) then clearly I can’t click ‘ignore’ because that is my responsibility so I go and deal with it, whatever that alert might be. But during the day, you know if things start flashing up and it’s not my patient…you know there’s a lot of patients in this hospital. I’m not going to respond to everything…”(Individual Interview 5)