Drug safety alerting in computerized physician order entry: Unraveling and counteracting alert fatigue

Computerized physician order entry systems (CPOEs) usually generate drug safety alerts to remind physicians to potentially unsafe situations. However, physicians may feel overwhelmed by high numbers of alerts that are not patient-tailored and they may consequently suffer from alert fatigue. Alert fatigue is the mental state that is the result of alerts consuming too much time and mental energy, which can cause relevant alerts to be unjustifiably overridden along with clinically irrelevant ones. Reasonâ?Ts model of accident causation helps to understand how a drug safety alerting system meant to reduce medication errors may provoke them. Low specificity, unclear alert information, unnecessary workflow disruptions and unsafe and inefficient alert handling add to the risk of alert fatigue. Drug safety alerts were overridden in 90% of cases and physicians often justified overriding by using incorrect rules or rules not applicable to the situation. A newly developed comprehensive test showed widely varying quality of drug safety alerting in Dutch hospital CPOEs. Counteracting alert fatigue appeared to be difficult. Turning off frequently overridden alerts hospital-wide was not feasible because of within-hospital differences in drug-related knowledge and routine monitoring practices. Levels of seriousness added to the alert text were perceived helpful but resulted in increased override rates. Directing alerts with respect to drug administration times to nurses was not accepted by the ward management. Preferred alert handling was hampered often because of low specificity, unclear alert recommendations and inefficient handling. This research generated unexpected results as well as insights how to improve drug safety alerting in CPOE.

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