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Improving Patient Safety by Reducing Alert Fatigue

When a team at St. Jude changed its system for drug interaction warnings, doctors had less alert fatigue and were less likely to override important alerts.
Improving Patient Safety by Reducing Alert Fatigue
Hospital hospital room exam room ER emergency room

Drug interactions are a serious hazard in hospitals and in the community. If patients receive prescriptions for incompatible medications, they can experience severe side effects that may even be life threatening. Electronic medical records are intended to warn prescribers and pharmacists about potentially dangerous interactions, but many do so indiscriminately. The result is something called alert fatigue.

Why Is Alert Fatigue Dangerous?

Think of it a bit like the boy who cried wolf. After the villagers came running to help him twice when there was no wolf, they didn’t pay attention to his next alert. So the wolf ate his sheep. When clinicians receive too many warnings, they may not pay attention to really important drug interactions that can cause patients serious harm.

Changing the Alert System to Reduce Alert Fatigue:

A team at St. Jude Children’s Research Hospital reviewed their alert system (Daniels et al, Pediatrics, Feb. 2019). They removed unnecessary alerts and provided additional information on the most important drug interactions. After they finished, they tracked clinicians’ reactions. Alert overrides dropped by 40 percent. One important change linked alerts to the patient’s laboratory data, making them much more targeted and less likely to result in alert fatigue.

The overhaul to the system made a significant impact. There were 40 percent fewer drug-drug interaction alerts cropping up for clinicians. Attending physicians actually had up to 82 percent fewer warnings about drug interactions. The changes in the system did result in two “patient safety events” during the study period. We don’t know whether those events resulted in patient harm, nor how many such events occurred during a similar time frame before the changes were undertaken.

The authors conclude:

“Our quality improvement effort refined 47% of all DDI alerts that were firing during historical analysis, significantly reduced the number of DDI alerts in a 54-week period, and established a model for sustained alert refinements.”

Learn More: 

We discussed alert fatigue, drug interactions and overmedication with Dr. Jennifer Jacobs in Show 1134: Do You Really Need That Pill?

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About the Author
Terry Graedon, PhD, is a medical anthropologist and co-host of The People’s Pharmacy radio show, co-author of The People’s Pharmacy syndicated newspaper columns and numerous books, and co-founder of The People’s Pharmacy website. Terry taught in the Duke University School of Nursing and was an adjunct assistant professor in the Department of Anthropology. She is a Fellow of the Society of Applied Anthropology. Terry is one of the country's leading authorities on the science behind folk remedies. .
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