Electronic Health Records

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Reducing Alert Fatigue Prevents Pharmacy Medication Errors

By Vera Gruessner

- Within the healthcare industry, as more health IT systems and EHR platforms were installed over the last few years in order to meet meaningful use requirements under the EHR Incentive Programs, the number of alert notifications that physicians receive has brought forth a renewed focus on alert fatigue. As the large amounts of notifications kept rising for doctors, many physicians and healthcare professionals began ignoring some of the alerts, which has negatively impacted patient safety.

Alert Fatigue

Alert fatigue is a serious problem for the healthcare sector, as certain drug allergies or negative drug reactions – which are often presented via alerts – could be ignored and a patient’s health could be at risk. However, a new solution called AlertSpace from First Databank could play a role in repairing some of the damage caused by alert fatigue. This web-based system allows healthcare professionals to customize alerts, improve specificity, and eliminate inconsequential alerts.

Joshua Schmees, system IT pharmacist from Hospital Sisters Health System, spoke with EHRIntelligence.com to provide his input on alert fatigue and the AlertSpace solution. First, Schmees explained how the AlertSpace platform follows AHRQ recommendations.

“With AlertSpace, we use the tool for a couple of reasons. We’re a multi-facility system so we have 10 hospitals that have individual EHRs, but with AlertSpace we used one drug information knowledge base load,” Schmees clarified. “With AlertSpace, we could make one change in one spot. For us, it was an efficiency model that worked well. In addition, from an alert fatigue perspective on the tool itself, I would have access to all the First Databank documentation as to the clinical content reference materials, specifics on the alerts and why they were built, and the category of severity. I could also use this to document and look at other information.”

“It really has a lot of different components within it that allows me to keep track of my documentation and streamline how I make a change in the EHR system,” he mentioned.

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When asked about some tips for reducing alert fatigue among healthcare providers, Schmees responded, “From my experience, one should look at all the information being provided making sure that it hits the right components. Is the alert firing at the right time? Is the alert meaningful? Do we always act on it 100 percent of the time? Does it make sense when it’s firing or is just going to be something that’s extra information that bogs down the provider?”

“Also, the severity of it is important. Is it something that, severity-wise, makes sense to stop and halt in the ordering process workflow? Or is it something that may be incidental or, based off case studies, rare? Some other things to focus in on from a pharmacy perspective is how fast medicines work,” Schmees mentioned. “For example, some medications have very long half-lives. So to fire the interaction right at the point of order entry when that interaction might take two weeks to occur in our acute care setting doesn’t always make a lot of sense.”

“If the alert specificity provided to the professional isn’t actionable, then sometimes the alert gets overridden because it doesn’t provide the same lab information that’s associated with it, age-related concerns, etc. Some of that isn’t specific enough to drill down and make that alert meaningful.”

When asked about his experience with AlertSpace and whether it reduced alert fatigue in his workflow, Joshua Schmees answered, “We have a scorecard for alert fatigue. We keep track of alerts that have popped up and made it through pharmacist verification. Using the AlertSpace tool, we only needed to change a minimal amount of interactions to see a significantly reduced volume.”

“Addressing 23 interactions gave us a decrease in more than 40 percent of our drug-drug interaction volume across our system,” he continued. “Over 100,000 alerts were present in our system, so it’s definitely been a helpful tool in making those changes quickly. Besides turning off an alert, sometimes we have to make a decision whether there’s one drug in particular that’s causing something to fire. What we’re able to do is to turn off that particular offending agent but still leave on the other drugs that are actually more significant.”

In response to the question, “Have you noticed on the job whether alert fatigue poses risk to patient safety?” Schmees answered, “I think if you go to any facility, alert fatigue poses a huge risk. Alert fatigue override rates can be up to 96 percent, which means only 4 percent of the alerts ever get addressed. For us, we’ve used the same barometers to keep track of how things are going.”

“For example, our override rate was about 88 percent, so 12-13 percent of alerts led to an action that prevented a medication error. We took the number of alerts and looked at how many times that provider erased or modified that order based on the occurring alert. We’re better than that 4 percent address rate, but it obviously doesn’t sound good in and of itself (12 percent),” he continued. “After we decreased our alert fatigue, we did see an increase in that number from 12 percent to about 17 percent depending on the month. We were actually catching about 200 more preventable medication errors off of those alerts. That’s a huge win in patient safety.”

When asked whether the AlertSpace platform reduces medical errors, Schmees explained, “We actually followed a drug allergy and looked at retrospective data over the course of a year at one institution to see, of all those alert fatigue events, did it cause any Adverse Drug Events? Did we give any reversal agents for allergic reactions? We did not have any reversal agents given for that allergy. This is causing 40 percent of our allergy noise. We don’t have data to support that we are seeing clinical events so we removed that.”

“We followed that allergy data going forward for four months and we had 424 Meta events documented and 19 of those were allergy-related. None of those 19 were related to the allergy change that we made. That really told us that we made a change that impacted alert fatigue significantly for us but didn’t lead to any negative outcomes.”

When asked about some of the biggest challenges of implementing the AlertSpace solution, Schmees replied, “One of our biggest challenges was developing our process which was a difficult because, as a multi-facility system, we didn’t initially think of making changes system-wide. With the AlertSpace tool, we had to make changes and agree upon them because they were going to affect every one of our facilities.”

“We formed two groups including a medication alerts group, which is the starting point, in which we involve pharmacists across the multi-facility system that are in different roles. I would suggest changes, they would review them and, once they approved, we would send the proposed changes onto our medical informatics committee.”

The last question posed to the system IT pharmacist was, “How can we get widespread adoption of tools like AlertSpace to address alert fatigue?”

“Articles in peer-review journals substantiate why it’s important. One of the biggest issues we encountered at the beginning was to get people comfortable with the understanding that alert fatigue is a problem. Seeing 80 percent of your alerts being overridden is a huge, negative problem and to be able to tweak and adjust those is okay,” he concluded. “[It’s important] to get people to feel comfortable and it’s going to lead to better outcomes for you as far as seeing those alerts and catching preventable errors.”




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