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Whats New in the
Patient Safety World
March 2021
ECRI Partnership
Whitepaper on Alert Fatigue
All would agree that
alerts generated by clinical decision support systems are valuable patient
safety tools. But weve all seen how alerts can be
obtrusive and interfere with clinician workflow, thus giving rise to alert
fatigue in which alerts are simply ignored or overridden.
ECRI's Partnership
for Health IT Patient Safety is a multi-stakeholder collaborative that sets
priorities in health IT safety. Youll recall we highlighted its previous work
on closing the loop (see our September 2018 What's New in the Patient Safety
World column ECRI Institute Partnership: Closing the Loop), which focused on improving communication
to prevent things from slipping through the cracks.
The Partnership has
now concluded efforts of a similar workgroup focused on finding ways to reduce
alert fatigue associated with Computerized Physician Order Entry (CPOE) systems.
Recommendations are included in their report Safe Practices to Reduce
CPOE Alert Fatigue through Monitoring, Analysis, and Optimization (ECRI
2021). The workgroup makes four main
safe practice recommendations:
- Governance: Identify,
develop, and execute a CDS and knowledge base governance plan.
- Monitoring: Gather
data and information using CDS-specific metrics and other tools to
identify real-time and/or near real-time CDS alert functioning and impact.
- Analysis: Regularly
assess, evaluate, and interpret metrics, functionalities, usability, and impact
to determine effectiveness and value while balancing and minimizing
burden.
- Optimization: Maximize the use of technology and
various tools to create and promote effective, targeted, relevant, and
routinely updated alerts.
The report
reiterates the 5 Rights model of clinical decision support (CDS) adopted from
Osheroff et al. (Osheroff
2012):
- The right information:
evidence-based, suitable to guide action, pertinent to the circumstance
- To the right person:
considering all members of the care team, including clinicians, patients,
and their caregivers
- In the right CDS intervention
format: such as an alert, order set, or reference information to answer a
clinical question
- Through the right channel:
for example, a clinical information system such as an electronic medical
record, personal health record, or a more general channel such as the
internet or a mobile device
- At the right time in workflow: for example, at time of decision, action,
or need
When we did our
first CPOE implementation back in 2007, we were flooded with suggestions for
potential alerts that could be used for patient safety. But we readily
recognized the need to limit such alerts in order to
avoid alert fatigue. We set up a multidisciplinary committee to assess all
suggested alerts and to monitor at specified intervals both the impact of such
alerts and any unintended consequences. Monitoring included documentation of
how often alerts triggered and what the acceptance and override rates were. In
addition, clinicians were interviewed to assess their impression of both the
utility and the degree of obtrusiveness of any alerts.
The Partnership
report provides excellent guidance in identifying alert metrics, asking the
following key questions:
- How many alerts fired and who
received them?
- Did the alert fire
appropriately or not?
- How did the alert recipient
interact with the alert?
- What was the impact of alerts on recipients?
The report stresses,
in initiating optimization efforts, that it is important to ask the following
questions:
- What problem is the alert
going to solve?
- Is the alert in line with the
goals and policies of the practice or organization?
- How will the alert impact the
clinicians workflow?
- Is the alert beneficial
(e.g., does it reduce adverse events, increase screening, or increase
referrals)?
- Is an alert the appropriate tool (i.e., is there another alternative to accomplish
the same goal)?
Wed like to emphasize that last point. In our
March 3, 2009 Patient Safety Tip of the Week Overriding
Alerts
Like Surfin the Web we noted that use of standardized order
sets may avoid the need to generate some alerts (though standardized order sets
can create some problems of the own, particularly when they contain outdated
information that is no longer appropriate).
We refer you to the
full Partnership report for details on all their recommendations. This is an
excellent resource that every organization using any form of clinical decision
support tools needs to review and incorporate their recommendations into their
own programs.
See some of our other
Patient Safety Tip of the Week columns dealing with unintended consequences of
technology and other healthcare IT issues:
- June 19, 2007 Unintended Consequences
of Technological Solutions
- May 20, 2008 CPOE Unintended Consequences
Are Wrong Patient Errors More Common?
- June 17, 2008 Technology Workarounds
Defeat Safety Intent
- August 26, 2008 Pattern Recognition and
CPOE
- September 9, 2008 Less is More
.and Do
You Really Need that Decimal?
- December 16, 2008 Joint Commission
Sentinel Event Alert on Hazards of Healthcare IT
- February 2009 Healthcare IT The Good and The Bad
- March 3, 2009 Overriding Alerts
Like Surfin the Web
- October 2009 A Cautious View on CPOE
- November 24, 2009 Another Rough Month for
Healthcare IT
- April 20, 2010 HITs Limited Impact on Quality To Date
- July 27, 2010 EMRs Still Have a Long
Way to Go
- March
22, 2011 An EMR Feature Detrimental to Teamwork and Patient Safety
- January
24, 2012 Patient Safety in
Ambulatory Care
- June
26, 2012 Using Patient Photos to Reduce CPOE Errors
- June 2012 Leapfrog CPOE Simulation: Improvement But
Still Shortfalls
- July 17, 2012 More on Wrong-Patient CPOE
- January 2013 More IT Unintended Consequences
- April 23, 2013 Plethora of Medication
Safety Studies
- April
30, 2013 Photographic
Identification to Prevent Errors
- October 8, 2013 EMR Problems in the ED
- March 11, 2014 We Miss the Graphic Flowchart!
- October 2014 Ebola Exposes Fundamental Flaw
- January 2015 Beneficial Effect of EMR on Patient Safety
- March 2015 CPOE Fails to Catch Prescribing Errors
- March 31, 2015 Clinical Decision Support for Pneumonia
- August 2015 Newborn Name Confusion
- December 2015 Opioid Alert Fatigue
- January 12, 2016 New Resources on Improving Safety of Healthcare IT
- January 19, 2016 Patient Identification
in the Spotlight
- February 9, 2016 It was just a matter of
time
- April 5, 2016 Workarounds Overriding
Safety
- May
2016 Name Confusion in the
Pharmacy
- May 3, 2016 Clinical Decision
Support Malfunction
- May 24, 2016 Texting Orders Is It
Really Safe?
- August 23, 2016 ISMP Canada: Automation
Bias and Automation Complacency
- November 22, 2016 Leapfrog, Picklists,
and Healthcare IT Vulnerabilities
- January 2017 Joint Commission Thinks
Twice About Texting Orders
- February 28, 2017 The Copy and Paste ETTO
- March 2017 Yes! Another Voice for
Medication e-Discontinuation!
- April 2017 How Much Time Do We
Actually Spend on the EMR?
- June 27, 2017 Texting We Told You
So!
- August 1, 2017 Progress on Wrong
Patient Orders
- January 2018 Can We Improve
Barcoding?
- January 16, 2018 Just the Fax, Maam
- January 30, 2018 Texting Errors Revealed
- June 19, 2018 More EHR-Related
Problems
- September 2018 More Clinical Decision
Support Successes
- December 11, 2018 Another NMBA Accident
- January 1, 2019 More on Automated
Dispensing Cabinet (ADC) Safety
- February 5, 2019 Flaws in Our Medication
Safety Technologies
- March 26, 2019 Patient
Misidentification
- May 2019 Too Much Time on the
EMR
- May 21, 2019 Mixed Message on Number
of Open EMR Records
- July 23, 2019 Order Sets Can Nudge
the Right Way or the Wrong Way
- September 10, 2019 Joint Commission Naming
Standard Leaves a Gap
- September 24, 2019 EHR-related Malpractice
Claims
- December 17, 2019 Tale of Two Tylers
- June 2020 EMR
and Medication Safety: Better But Not Yet There
- June 16, 2020 Tracking Technologies
- July 2020 Patient Requests for
EHR Corrections
- July 21, 2020 Is This Patient
Allergic to Penicillin?
- September 2020 More on Workarounds
- November 17, 2020 A Picture Is Worth a
Thousand Words
References:
Partnership for Health IT Patient Safety. Safe Practices to
Reduce CPOE Alert Fatigue through Monitoring, Analysis, and Optimization. ECRI
2021
https://d84vr99712pyz.cloudfront.net/p/pdf/hit-partnership/partnership_whitepaper_alertfatigue_final.pdf
(ECRI
2021)
Osheroff JA, Teich
JM, Levick D, et al. Improving outcomes with clinical
decision support: an implementers guide. 2nd ed. Chicago (IL): Healthcare
Information and Management Systems Society; 2012
https://www.amazon.com/Improving-Outcomes-Clinical-Decision-Support/dp/0984457739/ref=sr_1_1?dchild=1&keywords=Osheroff&qid=1614095482&s=books&sr=1-1
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