How to eliminate alert fatigue

Alert fatigue can desensitize clinicians, causing patient safety concerns.As caregivers, we all fall victim to “alert fatigue,” when the sheer number of alerts a clinician receives causes them to unknowingly miss important safety warnings. Ironically, all these alerts that are meant to improve patient safety can cause workers to become desensitized and potentially miss important warnings; from incessant smartphone buzzing, to tablet chimes or the blinking red indicators of your EHR.

Not everything is so dire, and we need to triage out the truly critical from the other serious notifications. In my opinion, the Agency for Healthcare Research and Quality (AHRQ) hits some great points in their very concise patient safety primer on the subject.

First, we need to increase alert specificity by getting rid of clinically inconsequential alerts. We should then conform alerts to individual patients and patient profiles. And finally, place all alerts on a tier system, according to severity. This could mean a color coded system, making higher-level alerts interruptive, or personalizing the warnings to the clinical user.

In the 21st century, EHRs are just another avenue for “noise” when not used to their proper extent. It’s even possible you’ve been interrupted once already reading this post. Wherever you turn, an alert wants you to know something, and now. Thankfully, using tried-and-true methods and best practices to weed out the commotion come along with the territory.

In the automotive world, hearing the “BING BING BING” of an unbuckled seat belt is clearly a “wanted alert” in the family car. But imagine a blind spot assistant feature telling you every time a car passed in your blind spot, even when you weren’t planning to change lanes. You would likely get tired of this, and begin to block it out.

For me, it goes back to the old adage “too much of a good thing can be bad.” To better illustrate my point, I’ll borrow an example from Dr. Steven Jones, MEDITECH’s Lead Physician Informaticist. In a way, alerts are comparable to a hearing aid. The first stage of a patient with a hearing aid is need: a person who cannot hear requires the problem rectified.

This stage is analogous to our pre-EHR paper world. Without alerts when writing progress notes or orders, there isn’t any noise. A paper record will not talk back at you, for better or worse.

The second stage for our hard-of-hearing patient is acquiring the hearing aid itself. Now all the noise is coming through, likely an overwhelming cacophony. Consider this our electronic stage - moving from paper to an EHR introduces all sorts of alerts and notifications within the system. The EHR user now needs to filter through the “noise” to find vital information.

In the third and final stage, he or she finely tunes their device to fit their exact needs. This is exactly what modern clinicians need. With refined alerts, caregivers “hear” just enough to be meaningful and to help make clinical decisions that improve patient safety.

This line of thinking is clearly a no-brainer, and thankfully metrics back it up.

A 2014 Public Library of Science article found that the telemetry monitors in an academic hospital's 66 bed adult intensive care unit generated more than 2.5 million alerts in one month, translating to 187 warnings per patient per day. And according to another study, CPOE systems generate warnings for 3-6% of all orders that are entered, meaning that a physician could easily receive dozens of warnings during a shift.

While this ICU study focused mostly on telemetry alerts, the comparison can easily be made to medication alerts received within an EHR. We get lots of warnings, but how many of them are meaningful? The vast majority of alerts generated by CPOE systems are clinically inconsequential. Clinicians ignore the bothersome, meaningless alerts but in turn, also ignore the critical alerts.

This results in the paradoxical increase in the chance that patients will be harmed. A July 2016 article from the AHRQ concluded that as physicians become increasingly inundated with alerts, they correctly ignore inconsequential alerts, but inadvertently ignore the critical notifications that warn of impending serious patient harm.

A study published in the Canadian Medical Association Journal (CMAJ) in 2010 indicated that clinicians did a better job with alerts if they required a response. And interestingly, they also found that even after overriding a warning, only 35% actually followed the guidance and continued to monitor for potential adverse effects.

Much like a hearing aid, a deft hand and some nuance will help separate what providers need to know from what caregivers need to act on right away. Alert fatigue can be a fact of life, whether you are on your phone, in the car, or navigating your EHR. We need to figure out a way to help our clinicians better understand these alerts in order to improve our patient care. After all, our patients lives are at stake. 


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Topics: Physician, How to, Patient Safety

Written by Kang Hsu, MD, Physician Champion, St. Joseph Health

Dr. Kang Hsu is a board certified internal medicine physician practicing as a hospitalist at St. Joseph’s Hospital in Orange, California. He serves as Medical Director of Clinical Documentation Improvement and is the lead physician at the hospital's Transitional Medical Clinic. He is also the Physician Champion of CIS at St. Joseph's Hospital. He received his Bachelor’s degree from the University of California, Berkeley and his Doctor of Medicine (M.D.) from Albert Einstein College of Medicine. He completed his residency training in Internal Medicine at Harbor-UCLA Medical Center in Torrance, California.

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