- Alerts are only modestly effective at best.
- Alert fatigue is common.
- Alert fatigue increases with growing exposure to alerts and heavier use of CPOE systems.
Indeed most side effect warnings are inserted because pharma legal teams insert reference to every case report, not matter how obscure. Otherwise- such non-medical counsels might argue- how could there be good defense against attribution of negligence, should a second atypical case pop up? Putting such warnings into the adverse effect section of the ubiquitous PDR provides the possibility of escaping a lawsuit on the basis of physician or patient contributory negligence. That is, the pharma defense team might argue, "they (the docs) did not (even) read the warnings!"
Attending to every one of the countless case-report engendered warnings would effectively take most medications- not to mention the clinicians- out of practical consideration. On the other hand, some alerts are very serious and represent preventable errors that can potentially be avoided. Balancing this voluminous input is hard on the human mind, and pretty much- without weighted prioritization- impossible for a machine. Hence, the machine creates noise- repeated alerts- that the mind must deal with, and clinicians, getting inundated with endless warnings and signals, start ignoring them, even perhaps overriding their demands.
Human-factors come into play. Protective desensitization to incoming stimuli is a necessary component of efficient cognitive activity. Who among us has not become resistant to the noisy environment of an ED, just so we could get our baseline thinking in order? The same can be said of a parent, working at home, with chattering children running about. Earplugs? Well, sometimes. But for the most part, many have learned to shut down the "noisy" input by "throwing an internal switch", one that no longer hears the kids screaming. Repeated alerts, as we all have experienced, soon become just background noise. Hopefully, thought, if the house is burning, the sound will be loud enough, different enough, for a red flag to arise.
The authors suggest:
- Increase alert specificity
- Tier alerts according to severity
- Make only high-level-severe- alerts interruptive
Some vendors have unfortunately left the job of tailoring alerts to the clinicians working at a client facility. Dumping all responsibility on the docs is truly unfortunate, not only because it means considerable extra work and expense for the clinician staff but also because it nominally absolves the vendor of appropriate involvement in the effectiveness and up to date accuracy of the product. The ability to do some local customization has definite value, but a balance between what the vendor inputs, and what the clinicians input, is necessary for a system to be effective, safe, and appreciated by all.
Our culture contains multiple myths and stories such as "The Boy Who Cried Wolf", and Chicken Little with the sky is falling. Alert fatigue is a real entity and will need careful analysis to allow the positive clinical decision support to be a facilitator toward better clinical care and outcomes.