Search results for "Information Professionals"

This study of a quality improvement initiative found that automated screening of prescribing data uncovered many potential adverse drug events. Prescribers were notified about these safety concerns, and almost 80% of these potential adverse drug events were resolved through prescription changes. The extent of patient harm which occurred or was averted was not reported. This work suggests that real-time data from electronic prescribing could be harnessed to improve patient safety, as others have suggested.

Users often bypass alerts meant to enhance the safety of medication ordering and dispensing technologies. This observational study at a large academic medical center found approximately one in five nonformulary medication alerts are inappropriately overridden. The authors suggest strategies that future research should examine for improving the design of nonformulary alerts.

Test result notification is a longstanding patient safety problem. This time series analysis examined changes in documented communication between the interpreting radiologist and the treating physician for abnormal test results following implementation of an electronic alert notification system. The system allows radiologists to send alerts within their workflow for synchronous communication via pager for critical results and asynchronous communication via email for abnormal but noncritical results with alerts persisting until acknowledged by treating physicians. The authors used an automated text searching algorithm to identify radiology reports with and without documented communication and employed manual record review and adjudication to detect abnormal findings. They found that the electronic alert system led to higher levels of documented communication for abnormal findings without increasing documented communication of normal reports, allaying concerns about alert fatigue. This work demonstrates how systems thinking about provider workflow can result in technology approaches to enhance safety.

Alert fatigue is the Achilles heel of medication ordering with computerized physician order entry. This randomized controlled trial found that the appropriateness of alert overrides increased with implementation of a customized list of alert override reasons, compared with default options, in a CPOE system. This demonstrates the need to develop more clinically relevant reasons for overriding alerts in order to enhance the safety of medication prescribing.

This study examined the effect of a custom alert intended to reduce medication-timing errors associated with introduction of computerized provider order entry, which can lead to too-frequent or missed doses of medications. Using a rigorous interrupted time-series design, researchers found fewer medication-timing errors after implementation of this alert. This work demonstrates how custom alerts developed by clinicians can harness the electronic health record to improve safety.

Design weaknesses for medical devices can remain unrecognized due to insufficient reporting and the tendency to place blame on the user rather than question whether the equipment functioned appropriately. Discussing flaws in health IT design and how they can contribute to patient harm, this commentary advocates for enhanced reporting of device-related incidents to raise awareness about risks and enable learning from errors.

Prior studies have shown that prescribing clinicians frequently override computerized alerts warning them of potentially harmful drug interactions. This study found that house staff and physicians with fewer patient encounters were more likely to ignore alerts—as were physicians who graduated from one of the top five medical schools in the United States. Understanding why clinicians override warnings is critical to combating alert fatigue.

Clinical decision support alerts can help identify potential drug–drug interactions, but they can also contribute to alert fatigue. This commentary provides recommendations to inform the design of decision support to address drug–drug interactions. The authors suggest that improvement strategies focus on standardizing terminology and visual cues.

Older patients are particularly vulnerable to medication errors, with certain high-risk medications accounting for a large proportion of adverse drug events in these patients. This study evaluated the effect of warnings within a computerized provider order entry (CPOE) system targeting prescribing of unsafe medications to patients aged 65 years and older. The warnings resulted in a significant decrease in prescribing of two of the three medications targeted over a 3-year period. The authors note that there were readily available, safer alternatives for those medications, but not for the drug which continued to be prescribed. Also, prescription rates of all three medications were unchanged in younger patients, indicating that the tailored nature of the alerts played a role in their effectiveness. While clinical decision support within CPOE does have some effect on safe prescribing, the use of computerized warnings of this type must be balanced against the very real possibility that alert fatigue may develop as a result.

This before-and-after study found that introduction of a tiered alert system for medication dosages in pediatric patients led to an increase in alerts, but also resulted in fewer overridden alerts and more medication order revisions. This work emphasizes the need to improve electronic medication alerts to make them more actionable and reduce alert fatigue.

This series of webinars shared insights from representatives from hospitals, professional groups, and vendors whom discussed a variety of strategies to support safe use of hospital alarm systems and programs that enhanced learning from these systems.

An electronic clinical decision support system for prescribing in the emergency department used tiered alerts with higher and lower urgency information in order to avoid alert fatigue.

In this retrospective review of pediatric medication alerts, more than 85% of dosing alerts presented to clinicians were inappropriate. Frequent incorrect alerts contribute to alert fatigue and make clinicians more likely to override appropriate warnings.

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.

Attempting to create algorithms to decrease false positive bedside alarms and concomitant alarm fatigue, this trial successfully used a combination of monitor parameters to retroactively predict code blue events.

Human factors engineering studies how users interact with technology and attempts to optimize systems to minimize unintended consequences in real-world usage. Computerized provider order entry (CPOE) systems offer considerable safety advantages, but in real-world situations, many CPOE systems have failed to achieve the anticipated results. This Australian study found that many clinicians did not use CPOE system features that were intended to improve efficiency and safety, possibly because doing so would have forced them to change their workflow substantially. This non-standard usage resulted in the generation of many clinically irrelevant alerts, likely contributing to alert fatigue and probably diminishing the overall safety performance of the system. The study highlights the need for usability testing and careful integration of new technology into existing clinician workflows.

Highlighting dangers presented by alarm fatigue, modification, and miscommunication, this article discusses strategies to reduce such incidents.

Anesthesia equipment alarms went off approximately once per minute during cardiac surgical procedures; however, 80% of these alarms had no clinical consequences. The difficulty of calibrating alarm systems was discussed in an AHRQ WebM&M interview with human factors engineering expert Donald Norman, PhD.

The phenomenon of alert fatigue, in which clinicians ignore safety reminders that are excessively frequent or clinically insignificant, has been well documented in the information technology literature. This time–motion study documents the same phenomenon in the intensive care unit (ICU), finding that clinicians ignored 41% of alerts. The authors provide suggestions for improving the specificity of alarm systems in the ICU.

"Alert fatigue" refers to the tendency of clinicians to ignore safety alerts—for example, warnings about potential drug interactions—if alerts are too frequent or perceived to be clinically irrelevant. However, in this study, less intrusive alerts that did not require physician response were not effective at encouraging use of recommended laboratory monitoring.