A recent article from HIMMS Insight focusses on Alert Fatigue and lays out the problem:
Medications can harm. Computerized medication solutions try to eradicate preventable medication errors at the cost of triggering high rates of irrelevant alarms – mostly around drug-drug interaction – causing physicians and pharmacists to override them.
The majority of alerts are categorized as ADE or Adverse Drug Event alerts with drug-drug interactions being the largest category of alerts:
“Drug-drug interactions are the primary contributor to our alert load,” suggests Michel Ochowski, Formulary Pharmacist at Group Health Cooperative of South Central Wisconsin (GHC-SCW) in the United States. He goes on to say that “both pharmacy and prescriber users aren’t finding value in the majority of alerts”. That is why the high rate of irrelevant alarms creates alarm fatigue, which, in turn, leads to alarm overrides, causing a new set of problems, as a relevant warning might potentially be dismissed.”
Indeed, when warnings are dismissed an Adverse Drug Event can occur and ADE’s are still a big problem and are at the root of many patient safety issues.
According to the German Institute for Medical Documentation and Information, more people die annually in the US, the UK, Norway and Denmark due to an ADE than from traffic accidents. According to this source, an estimated 770,000 patients per year suffer from some form of ADE when hospitalized in the US. A study on in-patient medication errors found that about 90% of them occur at either the ordering or transcribing stage. Causes of medication errors range from prescribing wrong medication, dose or frequency of intake; poor handwriting; ambiguous abbreviations, erroneous transcription of medication orders into a medication plan; not allowing for allergies and clinically relevant drug-drug interactions, to neglect of contraindications.
The article asks the question, “Can over-alerting be reduced in practice?” and describes how pharmacists at GHC-SCW were called on to help close the safety gap:
Ochowski explains: ”Our end users are getting overwhelmed with drug-drug interactions, our prescribers override alerts at a rate of 98%, the pharmacy team at 93.2%.” With the aim to cut disruptive alert rates, lower alert override rates and provide less urgent information on demand, GHCSCW started filtering alerts based on clinical metrics and clinicians’ input. As a result, two customized user filtering systems were established, one for physicians and one for pharmacists. “In 60 days, the number of alerts had dropped almost by half and override rates declined. Alert distribution also improved, with the pharmacy team managing two-thirds of the load, significantly reducing physicians’ burden,” recalls Ochowski.
The importance of the pharmacist is reinforced in InformationWeek article, “Alert Fatigue: Searching for a Cure,” which found most electronic medication alerts at Indianapolis VA are best interpreted by pharmacists and not prescribing clinicians. Alerts, generated by electronic health records systems (EHR), notify physicians of important information about their patients in order to make accurate, precise decisions but the prescriber often needs assistance in managing the alerts if they are related to drug issues.
VA and Regenstrief researchers observed 30 physicians, nurse practitioners, and pharmacists entering and processing a total of 320 outpatient prescription orders. They found that prescribing clinicians often were confused about why the EHR delivered alerts and determined that the electronic warnings tended to be oriented more toward pharmacists than toward those who write prescriptions.
“Prescribers are overwhelmed by the number of alerts, and studies suggest that alert designs do not fully support prescriber decision-making,” says an article in International Journal of Medical Informatics, the official journal of the European Federation of Medical Informatics.
My guess is that if prescriber physicians are experiencing alert fatigue, pharmacists will begin encountering alert fatigue as well, if they are not already doing so! Technology can help support pharmacists with alert fatigue by monitoring specific and critical high-alerts. An interesting case study rounds out the HIMMS Insight article:
Professor Walter Haefeli, Head of the Department Clinical Pharmacology and Pharmacoepidemiology, Heidelberg University Hospital, explains how his organization has dealt with reducing irrelevant alerts in electronic drug decision support systems: “For over 10 years, we have been using a prescription platform into which we have also integrated a drug information system. The latter alone gets accessed on our campus approximately one million times annually”. He continues, “during the same time, the hospital has been conducting studies into discovering medication errors and how to prevent them, often with the support of locally developed electronic tools.” The research revealed that by taking into consideration context-related and patient-specific data – such as kidney function, potassium values, dosage, timing, and order of medication intake – the likelihood of false alerts can be lowered substantially. Haefeli and his colleagues found that “alerting strategies considering patient and drug-specific information to generate specific alerts have the potential to reduce the alert burden by more than 90%”.
Are you experiencing high-alert fatigue in your pharmacy? Do you have a technology solution to help you manage your alerts? Is your health system using pharmacists to assist prescribers in managing alert fatigue? Have you built pharmacist safety checks into your processes by routing alerts?