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Alarm fatigue is an increasingly recognized safety concern. This retrospective cohort study found that primary care clinicians were more likely to override alerts when there were multiple alerts per patient, but overrides were not related to overall workload or repeated exposure to the same alert. The authors recommend reducing the number of alerts per patient to address alarm fatigue.

Prior research has shown that providers frequently override drug interaction alerts, sometimes as a result of alert fatigue. In this study, researchers observed providers as they completed medication orders, addressing both high- and low-severity drug interaction alerts using five distinct electronic health records in two countries. The authors found that providers engaged in complex clinical reasoning prior to declining an alert, balancing various aspects of patient care including safety- and patient-specific factors.

The availability of decision support in computerized provider order entry (CPOE) systems has improved the ability to detect and prevent medication errors before they reach patients. However, when CPOE systems generate an excessive number of safety warnings that prescribers must manually override, alert fatigue may occur. In this study, investigators used a trigger tool approach and reviewed all antibiotic prescriptions with overridden alerts. They found that antibiotic prescriptions with overridden alerts were associated with dosing errors. In many cases, antibiotic overdoses reached patients and led to symptoms. The investigators used this data to refine the alert system, which eliminated some useless alerts. The authors conclude that automated algorithm-based detection systems can enhance the relevance of CPOE medication alerts and thereby reduce medication errors. A recent WebM&M commentary described a medication overdose related to alert fatigue.

Labor and delivery care is considered high risk for sentinel events should something go wrong. This review discusses how audible surveillance in this setting can contribute to alert fatigue and distraction among nurses and raises concerns that no standards exist to improve the effectiveness of electronic fetal monitoring.

This study found that laboratory values designated as "abnormal" or "panic" in the electronic health record, which are considered passive alerts, are very common for patients in the intensive care unit. The authors suggest that these passive alerts contribute to the pervasive problem of alert fatigue in the intensive care unit.

Alert fatigue is known to contribute to medical error. This news article reports on the problem of clinically irrelevant alarms overwhelming clinicians and what hospitals and health information technology vendors are doing to decrease them. Strategies include applying human factors engineering concepts to alert triggers and designing spaces to reduce alarm-associated interruptions and fatigue.

Clinical decision support systems are intended to improve safety by providing clinicians with information about potential harms—principally harmful drug interactions and allergies—at the point of care. Analyzing more than 150,000 drug allergy warnings in the inpatient and outpatient settings within a single health care system, this study examined how often the warnings were overridden and the appropriateness of prescribers' reasons for doing so. Clinicians overrode 81% of warnings in hospitalized patients and 77% of alerts in outpatients. More than 96% of the overrides were judged appropriate by independent clinical reviewers. These proportions are similar to prior studies. A common appropriate reason for overriding was that the patient had actually tolerated the drug in question, leading the authors to call for improving the accuracy of allergy documentation in electronic medical records. A few classes of drugs accounted for a large proportion of overridden alerts, suggesting that enhancing the accuracy of allergy warnings for these drugs could significantly reduce the overall burden of alerts. Given that alert fatigue is an increasingly recognized patient safety hazard, creating tailored alerts could help clinical decision support systems achieve their potential to improve safety.

Alert fatigue is recognized as a barrier to patient safety and may particularly increase risks associated with medication prescribing. This study examined the frequency of manual overrides of alerts for medication allergies over a 10-year period. Clinicians were required to provide a reason for overriding the allergy alert. As with earlier studies, the rate of overrides was very high. Researchers determined that the alerts were irrelevant in more than half the cases. Providers also were more likely to override repeated alerts compared with new alerts. These results highlight the overuse of alerts in health care settings and the need to improve their use to effectively support patient safety.

The concept of "number needed to treat" is used to quantify the number of patients who would need to undergo therapy to prevent one adverse clinical outcome. This study of opioid prescribing in an academic emergency department found that prescribers had to view more than 123 unnecessary alerts to prevent one adverse drug event. Studies such as this help quantify the number needed to treat for computerized warnings, a critical step forward in understanding and mitigating alert fatigue.

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.

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.

A persistent challenge in patient safety is detecting and intervening in unsafe situations before patients are harmed. Trigger tools have been widely used in retrospective studies to identify and characterize adverse events, and this study reports on a novel use for triggers—detecting potentially harmful drug interactions during the computerized provider order entry process. Trigger alerts in a computerized provider order entry system at three hospitals (academic, community, and rural) were reviewed by a pharmacist, who then either personally made changes or contacted the prescribing physician. The triggers were developed by a multidisciplinary team involving clinicians and information technologists and were tailored to identify clinically significant medication errors. The authors found that more than 40% of the alerts required pharmacist intervention, and that over 90% of pharmacist recommendations were accepted by the prescribing physicians. Therefore, the triggers used in this study generated far fewer false-positive alerts than seen in other studies. The proliferation of false-positive warnings is a primary contributor to alert fatigue, and although this study did not directly measure this phenomenon, it is plausible that use of more tailored alerts could avert alarm fatigue.

Enhancing alarm management to decrease unnecessary alerts is a critical step in making decision support usable for health care professionals. This intervention study describes how inpatient pharmacists modified alerts on intravenous infusion pumps to reduce the number of clinically irrelevant alerts. A previous AHRQ WebM&M commentary describes consequences of overriding an important alert as a result of alarm fatigue.

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.

Alarm fatigue, in which clinicians ignore safety alerts if they are too frequent or perceived to be clinically irrelevant, can lead to lack of awareness of an unsafe situation. This concern is particularly acute in intensive care units where patients are typically monitored with multiple devices, each with alarms. This retrospective review examined all alarm data regarding physiologic monitoring, including electrocardiogram, blood pressure, and oxygenation, from five intensive care units in a medical center. The vast majority of alarms were false-positives. Inappropriate alarm settings, electrode failure leading to poor signal quality, and alerts for non-actionable events were common causes for unnecessary alarms. The authors call for improving device design and monitor algorithms in order to reduce alarm fatigue. A previous AHRQ WebM&M perspective discussed the safety of medical devices.

Researchers used rapid-cycle iterative interventions to improve drug interaction alerts by eliminating clinically irrelevant notifications. These efforts resulted in fewer alerts and fewer manual overrides of alerts without any serious safety events, emphasizing the often cited need to streamline clinical decision support to prevent alarm fatigue.

Clinicians use thousands of prescription medications during routine care, and new medications are regularly incorporated into practice. Confusion between medications with names that appear or sound similar is a common cause of medication errors. This observational study sought to determine whether a computerized provider order entry system—with an alert that prompted providers to enter the indication when certain medications were ordered and required users to click "OK" to ignore the alert, to add the drug to a problem list, or to cancel the order—identified drug name confusion errors. These alerts intercepted 1.4 drug name confusion errors per 1000 alerts. While authors recommend that these alerts be implemented to decrease medication errors, they suggest narrowing the number of medications selected to prompt alerts to reduce risk of alert fatigue. A previous AHRQ WebM&M commentary describes an incident involving a look-alike drug error and reviews strategies to enhance safety of medication selection.

Computerized provider order entry with clinical decision support can be a powerful tool for alerting clinicians to potential prescribing errors. This study investigated how often and why providers overrode drug–drug interaction (DDI) warnings in an outpatient system that had already been extensively modified to show only the most important alerts. Clinicians frequently overrode critical DDI warnings. More than 30% of alert overrides were considered inappropriate and put patients at significant risks for adverse events. In some of the appropriate alert overrides, clinicians indicated that they would "monitor as recommended" for possible DDI effects, but according to a detailed chart review only about one-third actually did so. This study suggests that medication alert overrides will likely remain an important source of patient harm despite significant efforts to reduce alert fatigue.