The AHRQ PSNet Collection comprises an extensive selection of resources relevant to the patient safety community. These resources come in a variety of formats, including literature, research, tools, and Web sites. Resources are identified using the National Library of Medicine’s Medline database, various news and content aggregators, and the expertise of the AHRQ PSNet editorial and technical teams.
Wright A, Ai A, Ash JS, et al. J Am Med Inform Assoc. 2018;25:496-506.
Clinical decision support (CDS) includes electronic alerts that can prevent errors. Excessive or erroneous alerts may lead to alert fatigue or other unintended consequences. Researchers used a blend of qualitative methods such as interviews and quantitative data like alert rates to develop a taxonomy of CDS alert errors. The taxonomy includes the origin of the error, which most commonly occurred with introduction of a new decision support rule, and describes the underlying reason for the error, such as problems with new terms, conceptualization, and building the rule as intended. Errors could cause an alert to fail to appear for a relevant situation or could cause an irrelevant or erroneous alert to appear. Most errors came to light through reports from users. The authors recommend classifying CDS alert errors using this taxonomy so that safety efforts will be consistent and actionable.
Embi P, Leonard AC. J Am Med Inform Assoc. 2012;19:e145-8.
Clinical decision support systems (CDSS) are being applied widely in patient safety, most frequently to provide alerts intended to prevent medication errors. The utility of such warnings is limited by alert fatigue—clinicians' tendency to ignore repeated alerts. This study of an alert within an electronic medical record designed to encourage participation in a clinical trial is relevant for CDSS designers, as it quantifies the degree of alert fatigue. The study found that response rates to the alert declined consistently over time in response to increased exposure to the alert. A recent commentary called for CDSS to be tailored to maximize safety outcomes while minimizing alert fatigue.