Alert fatigue a focus after patient's drug allergy warning missed
- Officials at Good Samaritan Medical Center in Brockton, Massachusetts, are taking steps to reduce alert fatigue following a December incident when a nurse ordered and a pharmacist approved a pain reliever to a patient whose EHR indicated a life-threatening allergy to the drug, The Boston Globe reports. Neither noticed a warning box that alerted them on their computers.
- The patient suffered a severe reaction to the drug, a nonsteroidal anti-inflammatory, requiring transfer to intensive care, but did recover.
- In a Jan. 31 letter, CMS threatened to kick Good Samaritan off the federal Medicare program if it didn't move quickly to prevent future risks. The hospital now requires requires pharmacists to talk with the doctor or nurse about alternative medications if a patient has a serious drug allergy, and two people must sign off on any switch. It also reduced from 14 to seven the list of reasons providers can override an allergy alert.
Alert fatigue and EHR medication errors are big problems for doctors and staff working in a hospital setting. In a 2014 study, alert fatigue was associated with a greater intention of physicians to quit their jobs. At high-turnover facilities, providers often felt the EHR notifications were of little value.
But it’s not just a matter of work-related frustration. As the Good Samaritan case makes clear, it’s also a patient safety issue. In a study last year in the Journal of the American Medical Informatics Association, nearly three-fourths of medication-related clinical decision support alerts in inpatients were overridden. Of the overrides, 40% were deemed inappropriate. And in a national survey, 19 of 20 hospitals said alert fatigue was their No. 1 safety concern.
The Joint Commission issued a Sentinel Event Alert on the subject and has developed strategies to address the problem.
EHRs have also been implicated in a growing number of malpractice claims. Frequent targets are design issues, lack of integration of hospital EHRs and absence or failure of alerts and alarms.
Between July 2014 and December 2016, EHRs figured in 66 malpractice claims, versus just two between 2007 and 2010, according to a study last fall by The Doctors Company. The study also found more EHR-related claims associated with inpatient rooms as opposed to hospital clinics, doctor offices, ambulatory surgery centers, labor and delivery and emergency rooms.
One way hospitals can reduce medication errors is properly implementing bar code medication administration systems, which require the clinician to scan a barcode on a patient wristband before giving medicine. That process checks with an EHR for patient allergies and potentially harmful drug interactions. But a recent Leapfrog Group report found fewer than 35% of hospitals meet all the group's standards for proper employment of the technology.
- The Boston Globe Brockton hospital staff overlooked warning about a deadly allergy. ‘Alert fatigue’ may be to blame
- Beckers Clinical Leadership & Infection Control Massachusetts hospital tackles alert fatigue after staff overlooked patient’s deadly allergy warning