Preventing Alert Fatigue

An article in CBC News Canada yesterday highlights the importance of preventing ‘Alert Fatigue’ in pharmacies.

A Go Public Report into the death of Helena Lambert, 76, in British Columbia, Canada, found that important warnings about the interaction between two of the medications dispensed were missed, even though software used in the pharmacy would have flagged the potential for an adverse reaction.

In the article the reporter acknowledges that more than 30,000 pharmacists work across Canada, and they prevent similar issues from occurring every day. Contributors to the report further acknowledge that pharmacies can be very busy places, where constant vigilance is demanded of each member of staff. As the role of technology in pharmacies and healthcare systems grows the number of alerts and required steps in processes of preparing, dispensing and administering medications can be very demanding. ‘Alert fatigue’ is a well documented phenomenon amongst healthcare workers and continues to be amongst the greatest challenges for healthcare systems in the rising role of IT in healthcare.

‘Alert Fatigue’ can cause healthcare professionals to ignore or dismiss important alerts, resulting in skepticism of the value of certain technologies, poor adoption and poor success rates of those technologies. ‘Alert fatigue’ mainly arises from alerts that the healthcare professional finds irrelevant, too repetitive, too disruptive on workflow, or too difficult to interpret.

Preventing ‘alert fatigue’ is the responsibility of the IT user, the IT provider and content providers. These key stakeholders must work together to the find the right balance between the needs of the healthcare professional, the business organisation, and the safety of the patient.

What can pharmacists do?

One important solution is to tier alerts based on severity. In your pharmacy practice make sure that where possible you have alerts tiered so those events which pose a higher risk are delivered in a different manner or format to those with lower risk.

What can pharmacists do?

Another simple solution is to monitor override rates. Use the learning available to organise a tiering system for staff as part of your policies and protocols. You can also share this learning with the IT provider or content provider, to improve alert mechanisms and avoid ‘alert fatigue’.

Team Communication

Alert fatigue is a very real problem which can result in serious patient harm. Make sure that you are aware of it, and plan preventative actions