The term “alert fatigue” is used to describe a phenomenon in which busy clinicians become desensitized to safety alarms—whether auditory or on a device screen—and cancel them out without taking action. It’s easy to see how this can happen: according to an article in American Nurse Today, an estimated 85 to 95 percent of these alarms require no intervention. But not all alerts are false, and there is a rising concern that alert fatigue will create a new category of adverse events and patient safety concerns. In April, 2015, the Joint Commission released a sentinel event alert calling for healthcare organizations to pay close attention to the issue of alert fatigue.
According to the Agency for Healthcare Research & Quality (AHRQ), most of the existing research on alert fatigue focuses on physician use of computerized order entry (COE) and clinical decision support. These studies led the AHRQ to conclude:
- Alerts are only modestly effective in improving the process of care (although COE systems have decreased common prescribing errors tremendously).
- Alert fatigue is very common, with clinicians canceling out the vast majority of alarms.
- Alert fatigue increases with heavier use of electronic systems.
Nurses are also exposed to a wide variety of alert-generating devices, from smart IV pumps to patient monitoring systems and the EMR. The AHRQ reports that:
A 2014 study found that the physiologic monitors in an academic hospital’s 66 adult intensive care unit beds generated more than 2 million alerts in one month, translating to 187 warnings per patient per day.
In 2011, the Boston Globe published an investigative report that identified more than 200 deaths in a five-year period that could be attributed to a physiological monitor alarm going unheeded.
One thing is certain – with inpatient nursing care, achieving an optimal workflow is of utmost importance. So nursing alerts must be designed not only to consider the potential for improved outcomes, but to fit into the accepted workflow process as well. When alerts come at a time or in a format that interrupt nursing workflows and productivity, they hinder rather than help us. And a surprising number of decision support alerts are irrelevant to the patient or to standard clinical practice. For example, dialysis clinics report having to routinely cancel out alerts for renal blood work values that are considered “normal” for dialysis patients. Critical care nurses have received “at risk of falls” alerts for heavily sedated ICU patients. And there have also been instances of “check pregnancy status” alerts for male patients.
A study published in the journal Computers, Informatics, Nursing reported on nurses’ reactions to EMR alert features, based on focus groups that were held at a chain of hospitals within the Allina Health System in the Midwest. The EMR used by the participating nurses used banner alerts to notify nurses if a patient was at risk of falls, hearing impaired, had trouble swallowing, etc. But the researchers found that nurses were distrustful of this information, often questioning the criteria used to generate the alert or preferring other sources of information (like verbal communication from other nurses). A large majority also said they cancelled out alerts that referred them to a “best practice” guideline that may or may not apply to a specific patient.
Other alerts came in a “pop-up” format and these usually required a nursing action (turning a patient to prevent pressure ulcers, filling in missing documentation, etc). They often prevented nurses from accessing other parts of the record until the alert was addressed in one way or another. The researchers found that these were often seen as intrusive and annoying, particularly if they came up at the beginning of a shift, when a nurse hadn’t yet had a chance to assess the patients. They write:
When asked about suggestions for future use of pop-ups and guidance for system designers, nurses felt that pop-ups should be used very selectively only for time-sensitive issues related to high-level importance measures. They also recommended using them only for one-time events rather than part of a nurse’s routine. For example, a pop-up alert telling the nurse that compression devices have been ordered 6 hours earlier but have not yet been applied, with a link to document application, might be appropriate. But the use of pop-ups to notify the nurse to check the compression devices regularly once they were applied would not be an appropriate use of the pop-up.
In a best case scenario, nursing alerts can draw attention to tasks that have been missed or are of urgent priority, prevent communication failures as shifts change, and prompt not only action, but reflection as well – which can give nurses additional opportunities to advocate for their patients.
As hospitals increasingly incorporate new technologies, you’ll most likely run across alert features that have limited functionality or that create inefficient workflow processes. As a nurse, you have a choice – when the technology isn’t working for you, you can create your own workarounds or you can speak up and advocate for improved technologies and processes, including redesigned alerts. It’s clear that improvements should be made – and who better to provide input than you, the frontline provider?
And if you’re really interested in technologies that increase patient safety, why not consider specializing in nursing informatics? Healthcare is in need of nurses who can analyze technologies from both the bedside and IT perspectives. An online MSN degree in nursing informatics is the perfect way to improve your knowledge, skills, and value to your organization.