Alert Fatigue and Patient Safety – AHRQ

Current context

Although only recently recognized, alert fatigue (and the unintended consequences of the computerization of health care) has become a high profile patient safety issue. The Joint Commission released a sentinel event alert in April 2015 calling for health care organizations to pay close attention to information technology as a safety issue. In order to mitigate these consequences—including alert fatigue—The Joint Commission recommended improving the culture of safety by creating a shared sense of responsibility between users and developers, paying careful attention to safe IT implementation, and engaging leadership to provide oversight of health IT planning, implementation, and evaluation.

There is intense interest in developing specific methods to combat alert fatigue, but as yet, there is no consensus on the optimal approaches. Solving alert fatigue will require use of the principles of human factors engineering as well as those of informatics, as the problem fundamentally arises from both the technology itself and how busy human beings interact with the technology. An AHRQ WebM&M commentary provided several suggestions on how to minimize alert fatigue in CPOE systems:

  • Increase alert specificity by reducing or eliminating clinically inconsequential alerts.
  • Tailor alerts to patient characteristics and critical integrated clusters of physiologic indicators. For example, incorporate renal function test results into the alert system so that alerts for nephrotoxic medications are triggered only for patients at high risk.

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2010 © Foro Latinoamericano Colaborativo en Calidad y Seguridad en Salud

Desarrollado por IECS (Instituto de Efectividad Clínica y Sanitaria)

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