A clinical case of electronic health record drug alert fatigue: consequences for patient outcome.

William Carspecken; Paul J Sharek; Christopher A Longhurst; Natalie M Pageler

Commentary

A clinical case of electronic health record drug alert fatigue: consequences for patient outcome.

June 12, 2013

Carspecken W, Sharek PJ, Longhurst CA, et al. Pediatrics. 2013;131(6):e1970-e1973.

View more articles from the same authors.

This commentary describes an incident involving an inappropriate override of a drug allergy alert and details changes the hospital made in its medication allergy alert system in response to the event.

PubMed citation

Available at

Related Resources From the Same Author(s)

Decrease in hospital-wide mortality rate after implementation of a commercially sold computerized physician order entry system.

May 12, 2010

Improving communication with primary care physicians at the time of hospital discharge.

February 8, 2017

Perceived factors associated with sustained improvement following participation in a multicenter quality improvement collaborative.

June 29, 2016

Physician burnout in the electronic health record era: are we ignoring the real cause?

May 9, 2018

Crowdsourcing diagnosis for patients with undiagnosed illnesses: an evaluation of CrowdMed.

February 3, 2016

Safety stop: a valuable addition to the pediatric universal protocol.

September 5, 2018

Temporal trends in rates of patient harm resulting from medical care.

December 1, 2010

Development, testing, and findings of a pediatric-focused trigger tool to identify medication-related harm in US children's hospitals.

April 16, 2008

Adverse events in the neonatal intensive care unit: development, testing, and findings of an NICU-focused trigger tool to identify harm in North American NICUs.

October 25, 2006

Self-reported adherence to high reliability practices among participants in the Children's Hospitals' Solutions for Patient Safety Collaborative.

December 12, 2018

Children's hospitals' solutions for patient safety collaborative impact on hospital-acquired harm.

September 6, 2017

National trends in safety performance of electronic health record systems in children's hospitals.

October 12, 2016

Quantifying discharge medication reconciliation errors at 2 pediatric hospitals.

October 27, 2021

Rates of medication errors among depressed and burnt out residents: prospective cohort study.

February 20, 2008

Implementing delivery room checklists and communication standards in a multi-neonatal ICU quality improvement collaborative.

August 3, 2016

Simulation-based medical error disclosure training for pediatric healthcare professionals.

September 26, 2007

Using a pediatric trigger tool to estimate total harm burden hospital-acquired conditions represent.

July 11, 2018

Performance characteristics of a methodology to quantify adverse events over time in hospitalized patients.

September 8, 2010

Bending the patient safety curve: how much can AI help?

February 1, 2023

Telehealth in the COVID-19 era: a balancing act to avoid harm.

February 17, 2021

Effects of the Accreditation Council for Graduate Medical Education duty hour limits on sleep, work hours, and safety.

August 13, 2008

Effect of a rapid response team on hospital-wide mortality and code rates outside the ICU in a children’s hospital.

November 21, 2007

Comparing NICU teamwork and safety climate across two commonly used survey instruments.

November 30, 2016

Burnout in the NICU setting and its relation to safety culture.

May 7, 2014

Diagnostic errors in paediatric cardiac intensive care.

February 21, 2018

Performance of the Global Assessment of Pediatric Patient Safety (GAPPS) tool.

June 15, 2016

Exposure to Leadership WalkRounds in neonatal intensive care units is associated with a better patient safety culture and less caregiver burnout.

June 4, 2014

The correlation between neonatal intensive care unit safety culture and quality of care.

February 6, 2019

Decreasing handoff-related care failures in children's hospitals.

August 13, 2014

Development of an electronic pediatric all-cause harm measurement tool using a modified Delphi method.

December 7, 2016

Implementation of a standardized postanesthesia care handoff increases information transfer without increasing handoff duration.

January 14, 2015

A trigger tool to detect harm in pediatric inpatient settings.

June 3, 2015

Comparing the utility of a standard pediatric resuscitation cart with a pediatric resuscitation cart based on the Broselow tape: a randomized, controlled, crossover trial involving simulated resuscitation scenarios.

October 5, 2005

An intervention to decrease narcotic-related adverse drug events in children's hospitals.

October 29, 2008

Adverse events in hospitalized pediatric patients.

July 25, 2018

Safety climate, safety climate strength, and length of stay in the NICU.

November 20, 2019

The relationship between high-reliability practice and hospital-acquired conditions among the Solutions for Patient Safety Collaborative.

October 20, 2021

Changes in efficiency and safety culture after integration of an I-PASS-supported handoff process.

February 3, 2016

Adherence to recommended electronic health record safety practices across eight health care organizations.

May 16, 2018

Burnout in the neonatal intensive care unit and its relation to healthcare-associated infections.

June 14, 2017

Prevalence of adverse events in pediatric intensive care units in the United States.

October 13, 2010

Structured override reasons for drug–drug interaction alerts in electronic health records.

May 15, 2019

Identifying what is known about improving operating room to intensive care handovers: a scoping review.

February 28, 2018

Association between hospital acquired harm outcomes and membership in a national patient safety collaborative.

August 10, 2022

Increased appropriateness of customized alert acknowledgement reasons for overridden medication alerts in a computerized provider order entry system.

January 6, 2016

The preventive surgical site infection bundle in colorectal surgery: an effective approach to surgical site infection reduction and health care cost savings.

September 10, 2014

Teaching a 'good' ward round.

April 22, 2015

Patient misidentification in laboratory medicine: a qualitative analysis of 227 root cause analysis reports in the Veterans Health Administration.

February 17, 2010

Use of simulation to assess electronic health record safety in the intensive care unit: a pilot study.

April 24, 2013

Standardized admission order set improves perceived quality of pediatric inpatient care.

April 1, 2009

Medication errors: an overview for clinicians.

September 17, 2014

Myths and realities of the 80-hour work week.

August 16, 2006

An objective study of the impact of the electronic medical record on outcomes in trauma patients.

November 21, 2012

Critical diagnoses (critical values) in anatomic pathology.

August 9, 2006

Safely practicing in a new environment: a qualitative study to inform physician onboarding practices.

May 13, 2020

Novel use of electronic whiteboard in the operating room increases surgical team compliance with pre-incision safety practices.

March 14, 2012

Patient safety during sedation by anesthesia professionals during routine upper endoscopy and colonoscopy: an analysis of 1.38 million procedures.

April 20, 2016

Association of clinical specialty with symptoms of burnout and career choice regret among US resident physicians.

September 26, 2018

Implementing patient safety practices in small ambulatory care settings.

July 19, 2006

Inappropriate medication use in the elderly: results from a quality improvement project in 99 primary care practices.

April 23, 2008

Latency of ECG displays of hospital telemetry systems: a science advisory from the American Heart Association.

October 10, 2012

Evaluation of interventions to improve inpatient hospital documentation within electronic health records: a systematic review.

August 21, 2019

The impact of video games on training surgeons in the 21st century.

February 28, 2007

Trends in anesthesia-related liability and lessons learned.

March 6, 2019

E-prescribing and adverse drug events: an observational study of the Medicare Part D population with diabetes.

March 22, 2017

Teaching medical error apologies: development of a multi-component intervention.

July 6, 2011

Electronic medical record availability and primary care depression treatment.

September 26, 2012

Association of perceived medical errors with resident distress and empathy: a prospective longitudinal study.

September 6, 2006

Medication safety in primary care practice: results from a PPRNet quality improvement intervention.

July 11, 2012

Catastrophic medical malpractice payouts in the United States.

September 10, 2014

Wellbeing, burnout, and safe practice among healthcare professionals: predictive influences of mindfulness, values, and self-compassion.

June 8, 2022

Burnout and medical errors among American surgeons.

December 9, 2009

Effectiveness of surgical safety checklists in improving patient safety.

April 27, 2016

Meaningful Use stage 2 e-prescribing threshold and adverse drug events in the Medicare Part D population with diabetes.

May 20, 2015

Overdiagnosis and overtreatment as a quality problem: insights from healthcare improvement research.

May 9, 2018

Systematic review of physiologic monitor alarm characteristics and pragmatic interventions to reduce alarm frequency.

January 27, 2016

Computerized physician order entry in US hospitals: results of a 2002 survey.

March 6, 2005

National improvements in resident physician-reported patient safety after limiting first-year resident physicians' extended duration work shifts: a pooled analysis of prospective cohort studies.

May 25, 2022

Rate of undesirable events at beginning of academic year: retrospective cohort study.

October 28, 2009

Housestaff and medical student attitudes toward medical errors and adverse events.

August 1, 2007

The value of autopsies in the era of high-tech medicine: discrepant findings persist.

April 9, 2014

A blueprint for success: implementation of the Center for Medicare and Medicaid Services mandated anesthesiology oversight for procedural sedation in a large health system.

June 15, 2022

Balancing patient-centered and safe pain care for nonsurgical inpatients: clinical and managerial perspectives.

January 16, 2019

Workplace bullying in the OR: results of a descriptive study.

November 13, 2013

Spreading a strategy to prevent suicide after psychiatric hospitalization: results of a quality improvement spread initiative.

October 5, 2022

A review of patient safety measures based on routinely collected hospital data.

April 18, 2012

Early impact of the 2011 ACGME duty hour regulations on surgical outcomes.

January 13, 2016

A family-centered rounds checklist, family engagement, and patient safety: a randomized trial.

May 31, 2017

Dying for the weekend: a retrospective cohort study on the association between day of hospital presentation and the quality and safety of stroke care.

July 25, 2012

Innovation and teamwork: introducing multidisciplinary team ward rounds.

April 26, 2006

Physicians, information technology, and health care systems: a journey, not a destination.

March 6, 2005

Incidence and root cause analysis of wrong-site pain management procedures: a multicenter study.

March 31, 2010

The trainee's voice: recognising the importance of preoperative briefings for surgical trainees.

May 7, 2014

Reasons provided by prescribers when overriding drug–drug interaction alerts.

November 28, 2007

Are parents who feel the need to watch over their children's care better patient safety partners?

December 6, 2017

The role of talking (and keeping silent) in physician coping with medical error: a qualitative study.

August 8, 2012

Inpatient suicide: preventing a common sentinel event.

March 25, 2009

Computerized decision support to reduce potentially inappropriate prescribing to older emergency department patients: a randomized, controlled trial.

September 30, 2009

Computerized decision support for medication dosing in renal insufficiency: a randomized, controlled trial.

June 16, 2010

Changing our culture: adopting the military aviation safety system.

July 16, 2014

Related Resources

Patient Safety Innovations

Remote Response Team and Customized Alert Settings Help Improve Management of Sepsis

May 31, 2023

Interview

In Conversation with Susan McGrath, PhD and George Blike, MD about Surveillance Monitoring

April 26, 2023

Perspective

Surveillance Monitoring to Improve Patient Safety in Acute Hospital Care Units

April 26, 2023

Perspectives on Safety

Annual Perspective

Technology as a Tool for Improving Patient Safety

March 29, 2023

Health system redesign of cardiac monitoring oversight to optimize alarm management, safety, and staff engagement.

December 14, 2022

The potential for leveraging machine learning to filter medication alerts.

May 4, 2022

The effectiveness of interruptive prescribing alerts in ambulatory CPOE to change prescriber behaviour and improve safety.

May 5, 2021

Impact of alarm fatigue on the work of nurses in an intensive care environment--a systematic review.

February 3, 2021

Emergency department monitor alarms rarely change clinical management: an observational study.

September 16, 2020

Lessons learned from medical malpractice claims involving critical care nurses.

August 5, 2020

The tradeoffs between safety and alert fatigue: data from a national evaluation of hospital medication-related clinical decision support.

July 29, 2020

Assessment of health information technology-related outpatient diagnostic delays in the US Veterans Affairs health care system: a qualitative study of aggregated root cause analysis data.

July 22, 2020

How real-time data can change the patient safety game.

July 22, 2020

Systemic defenses to prevent intravenous medication errors in hospitals: a systematic review.

July 1, 2020

Team-based intervention to reduce the impact of nonactionable alarms in an adult intensive care unit.

November 6, 2019

Patient Safety Primers

Alert Fatigue

September 7, 2019

To catch a killer: electronic sepsis alert tools reaching a fever pitch?

August 28, 2019

Transcription errors of blood glucose values and insulin errors in an intensive care unit: secondary data analysis toward electronic medical record–glucometer interoperability.

May 29, 2019

Intensive care medicine in 2050: preventing harm.

May 1, 2019

Safety enhancements every hospital must consider in wake of another tragic neuromuscular blocker event.

January 23, 2019

Evaluation of harm associated with high dose-range clinical decision support overrides in the intensive care unit.

January 23, 2019

Solving alarm fatigue with smartphone technology.

January 23, 2019

Trigger alerts associated with laboratory abnormalities on identifying potentially preventable adverse drug events in the intensive care unit and general ward.

August 1, 2018

Principles of automation for patient safety in intensive care: learning from aviation.

June 6, 2018

Designing and evaluating an automated system for real-time medication administration error detection in a neonatal intensive care unit.

February 21, 2018

Case not closed: prescription errors 12 years after computerized physician order entry implementation.

January 31, 2018

February 8, 2017

Data-driven implementation of alarm reduction interventions in a cardiovascular surgical ICU.

February 8, 2017

Raising an alarm, doctors fight to yank hospital ICUs into the modern era.

September 21, 2016

Automated identification of antibiotic overdoses and adverse drug events via analysis of prescribing alerts and medication administration records.

August 24, 2016

See More About The Topic

Intensive Care Units

Health Care Providers

Quality and Safety Professionals

Information Professionals

Engineers

A clinical case of electronic health record drug alert fatigue: consequences for patient outcome.

Remote Response Team and Customized Alert Settings Help Improve Management of Sepsis

Alert Fatigue

Connect With Us

Sign up for Email Updates

Agency for Healthcare Research and Quality

A clinical case of electronic health record drug alert fatigue: consequences for patient outcome.

Remote Response Team and Customized Alert Settings Help Improve Management of Sepsis

Alert Fatigue

Connect With Us

Sign up for Email Updates

Agency for Healthcare Research and Quality

PSNet Log in

Submit Your Case

Continue as a Guest

Continue Logged In

Submit Your Case

Continue as a Guest

Already have a PSNet

Account?

New Users

Submit Your Innovations

Continue as a Guest

Continue Logged In

Submit Your Innovations

Continue as a Guest

Continue logged in

New Users to the PSNet site