Study examines negative consequences of EHR alert fatigue

While providers increasingly embrace clinical decision support tools to improve care delivery, an overabundance of alerts in the EHR may negatively impact patient health and outcomes, according to a study featured in the June issue of Pediatrics.

The authors examined the case of a two-year-old patient who experienced complications as a result of an extended series of non–evidence-based alerts in the EHR.

The boy, who had a sulfonamide antibiotic allergy documented in the EHR, was admitted to the pediatric intensive care unit at Stanford University’s Lucile Packard Children’s Hospital with respiratory stress and a rash. The clinical staff had overrode more than 100 alerts over a one-month period due to a potential drug-allergy cross reactivity with chlorothiazide and furosemide—treatment required for his condition. When his condition worsened, a concern for a true allergic hypersensitivity prompted staff to add a furosemide allergy to the EHR.

“Desensitization to EHR drug alerting by the deluge of overrides, however, resulted in temporary continued administration, over the course of one night, of the now inappropriate furosemide medication,” C. William Carspecken, MSc, MBA, department of biomedical informatics, Stanford University and colleagues wrote. “This event complicated the evaluation and treatment of his worsening, desquamating rash.”

Complicating matters was the discovery that the young patient was not in fact allergic to sulfonamide medications. The patient eventually died after developing fungal pneumonia with subsequent respiratory failure and septic shock. “Although the patient’s clinical course was complicated by many factors, the inappropriate allergy overrides further confused the situation,” the authors wrote.

The threat of missing a rare event must be balanced with the dangers of burdening clinicians with unnecessary alerts, Carspecken et al concluded. True incidences of substance intolerance, especially in pediatric medicine, lack clarity and often the EHR systems are not updated to incorporate new clinical evidence.

“Careful consideration to eliminate medication pairings alerts that pose a minimal theoretical risk of true hypersensitivity is critical,” according to the study. The authors noted that staff physicians, pharmacists and informaticists worked with the EHR vendor to modify and improve the allergy alerting system after the incident at Lucile Packard Children’s Hospital.

The authors also recommended the creation of a tort “safe haven” to allow experimentation with evidence-based clinical decision support software systems to protect both clinicians and software vendors working to improve patient safety.