Health care’s innate complexities necessitate that health care professionals retain large volumes of clinical data. The electronic health record (EHR) is the primary housing for this clinical data and often contains a clinical decision support component. In fact, decision support will soon be necessary to satisfy meaningful use requirements. The idea is that these systems can make patients safer by tracking specific kinds of patient data and generating patient-specific alerts that can notify caregivers of potential pitfalls. Decision support alerts can help practitioners adhere to certain standards of care, and they often aid in alerting to potential drug interactions when medications are ordered.
A 2009 study published in the Archives of Internal Medicine, however, reported that clinicians writing medication orders overrode up to 91 percent of their drug interaction alerts. The issue stems from a problem that’s been dubbed “alert fatigue.” It can arise when:
- The volume of alerts becomes so excessive that we cancel them out without really paying attention.
- We’ve learned through experience that most alerts are false positives.
- The alerts come at a time or in a format that interrupts our workflow or productivity – in other words, they hinder us rather than help us.
- Too many alerts are irrelevant to the patient or to standard clinical practice. (Clinicians have actually reported receiving “at risk of falls” alerts for heavily sedated and intubated ICU patients, and “check pregnancy status” alerts for male patients.)
The frustrations associated with alert fatigue can have a profound effect on patient safety. If we override every alert automatically, we risk missing something that might have otherwise saved a life. Yet who wants to work with electronic tools that aren’t user friendly? Since the concept of alert fatigue has become more widely recognized, some hospitals are reconfiguring their decision support systems and designing customized rules for when an alert appears. Overall, the industry consensus when it comes to medication decision support is that the informaticians and programmers who create these systems must aim to improve the specificity of alerts and design alerts that have higher user-acceptance.
Decision support, alerts, and nursing practice
Decision support alerts can help nurses implement best practices in inpatient settings. However, although research studies have been conducted on the way physicians use medication alerts, the health care technology industry has paid little attention to nursing alerts.
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.
A study published in the journal Computers, Informatics, Nursing recently reported on nurses’ reactions to EHR alert features, based on focus groups that were held at a chain of hospitals within the Allina Health System in the Midwest. Results from the study indicate that nurses experience alert fatigue differently than physicians during the prescribing process.
The EHR used by the nurses participating in the focus groups features banner alerts to notify nurses if a patient is at risk of falls, is hearing impaired, has a trouble swallowing, or other concerns. Researchers found that nurses were distrustful of this information, often questioning the criteria used to generate the alert or preferring other sources of information (e.g., verbal communication from other nurses). A large majority of the study participants 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 come in a “pop-up” format, often requiring a nursing action such as turning a patient to prevent pressure ulcers or filling in missing documentation. These pop-up messages often prevent the nurse from accessing other parts of the record until the alert is addressed. The researchers found that these are often seen as intrusive and annoying, particularly if they come up at the beginning of a shift, when a nurse hasn’t yet had a chance to tend to 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 highlevel 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 move toward electronic records, you’ll most likely run across 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? Health care 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.
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