Between alert fatigue and patient safety: finding the right balance

Inspired by a true story. Friday evening. 7 p.m. Mr. Lambert has finally been discharged from the hospital. After his long stay, he's happy to be going home. Unfortunately, he's not out of the woods yet.

On the way back to his house, he stops at the local pharmacy to fill his new prescriptions. Mr. Lambert has been a customer at this pharmacy for several years now, and he trusts his pharmacist implicitly. But it's a busy night. And in the hustle and bustle, between multiple requests for advice, a call from a doctor, and a line of people all impatiently waiting for their medication, the pharmacist misses an alert for a potentially dangerous drug interaction.

This critical alert should have caught the pharmacist's attention. Unfortunately, amid all the activity that evening, it went unnoticed. Mr. Lambert leaves the pharmacy with his new medication in hand. But after a few days, his condition deteriorates and he begins to experience serious side effects. In the end, he has to be readmitted to the hospital.

Could this situation have been avoided?

The real consequences of information overload

As pharmacists, we have to cope with daily information overload, which is only compounded by numerous technological advances and the rapid evolution of pharmacy practice. Fortunately, a number of tools—most notably decision-support systems—have become an integral part of our work. They help us care for our patients and keep them safe by flagging potential problems, such as drug interactions, overdosing, and warnings related to medical conditions.

However, when combined with the work overload currently affecting all health care workers, the sheer volume of information and the frequency with which it is exchanged can have harmful consequences.

• It becomes more difficult to distinguish between crucial information and complementary information, which can result in oversights. 
• The more alerts people receive, the more they will tend to tune them out, even when the alerts are urgent.

This phenomenon is known as alert fatigue, and anyone can be affected by it. It occurs when exposure to a high number of irrelevant alerts causes someone to become desensitized and ignore future alerts out of habit. You could say it's a sort of defence mechanism.

Alert fatigue can also be experienced by the general public. A good example of this is COVID-19 messaging. The high volume of alerts and constantly changing guidelines during the pandemic may have caused many people to become desensitized. To ensure that the desired messages were conveyed, the Government of Canada even issued recommendations on the subject.

Alert fatigue in the health care sector 

Alert fatigue has been commonplace in the health care sector for decades and is now widely recognized as a national concern, often due to the absence of an action plan to address it.

For example, one study found that up to 71.9% of alerts are ignored by pharmacists.⁽³⁾ In my opinion, this figure is cause for reflection, at both an individual and collective level.  Why is it so high?

There are several possible causes:

• Too many alerts
• Difficulty distinguishing between critical and complementary information
• A lack of specificity in alerts
• A lack of customization according to the type of practice
• A need for training on how to interpret alerts

Could a lack of trust in the tool also play a role? After receiving a number of irrelevant alerts, a pharmacist may well start to question the effectiveness of the tool itself, leading them to ignore subsequent alerts. These are all questions worth considering.

A look at the literature on this subject

To date, alert fatigue has been the subject of numerous studies, and several strategies have been proposed to combat it. One potentially promising model is proposed in the article “A framework for evaluating the appropriateness of clinical decision support alerts and responses.” The proposed conceptual framework relies on a panel of experts to assess not only the relevance of alerts themselves, but also the resulting clinical responses. The authors posit that applying this evaluation framework may provide a more complete understanding of the effectiveness of clinical alert systems and the true impact they have on care delivery. A growing body of literature suggests that the relevance of the response is dependent on the initial relevance of the alert.

Evaluating the response to alerts can help ensure that pharmacists both interpret the information correctly and properly apply it when treating their patients. In a scenario where any problems are flagged by the therapeutic advisor and all alerts are seen and understood, but the expected response is still not achieved, the effectiveness of the alert tool could be called into question.

To counter this problem, several studies suggest solutions such as the following:

• Customized alerts
• Prioritization and alert levels
• Training for the people who receive alerts
• Database optimization

These studies also highlight the active role pharmacists play in evaluating alerts: by helping to identify relevant alerts, they can directly contribute to reducing the phenomenon of alert fatigue.

If you would like to learn more about the different proposed strategies and recommendations, I suggest reading these articles:

• The clinical pharmacist’s role in enhancing the relevance of a clinical decision support system
• Hospital Pharmacists' Perceptions and Decision-Making Related to Drug-Drug Interactions 

Solutions to combat alert fatigue: A personal perspective

As a health care professional, I have a particular stake in reducing alert fatigue. As a pharmacist and product owner for the RxVigilance decision-support tool at Vigilance Santé, I consider myself lucky to be able to take steps to address this issue and help reduce alert fatigue among my peers.

Of course, regardless of which hat I'm wearing, the questions I ask myself, or the comments I receive, the issue of alert fatigue remains a major challenge that we must confront in order to find effective solutions that health care professionals trust. I'm committed to updating our tool in a timely manner and ensuring that it supports health care professionals in making informed decisions to keep their patients safe.

Because of their varied practices, pharmacists have different needs and expectations. Some say they're not getting all the necessary alerts, while others complain that they receive too many. How do you determine whether a piece of information is crucial enough to warrant the pharmacist's attention? It's a question we think about every day! 

Problem solved: A case study from our company 

When an alert is generated for the first time, it's especially important to read and assess it. Once the assessment has been done and the pharmacist has taken the appropriate action—say, adjusting a treatment—the alert may not need to be reviewed again in future. It's in situations like these where repeated exposure to alerts that don't require a response can lead to alert fatigue.

To resolve this issue, Vigilance Santé has developed a function to manage alerts displayed by the RxVigilance decision-support tool. This feature enables pharmacists to document the actions taken in response to an alert so they can prioritize care and focus on alerts that have never come up before.

I believe this feature can have a significant impact on pharmacists' day-to-day practice and, in particular, help increase their diligence and reduce information overload. If your decision-support tool has a similar functionality, it will become indispensable to your practice!

How do you find the right balance?

Mr. Lambert's story highlights the realities faced by pharmacists and effectively illustrates the complex issue of alert fatigue in the pharmacy sector. Alert fatigue affects not only pharmacists, because of the constant flow of information that can contribute to exhaustion, but also patients, whose safety may be compromised as a result.

Every time a pharmacist dispenses a drug or gives advice, they must consult the patient's file. By the end of their shift, they have had to take in a huge amount of information. And that's just one component of their job!

Given their expanding role and evolving practices, pharmacists need effective tools to support them in caring for patients. Software developers play a crucial role in creating effective tools. It's important for them to work closely with professionals for two reasons:

• To understand their specific needs
• To implement a rigorous evaluation system that ensures continuous improvement

Research in this field and continuous improvement are crucial to understanding the long-term implications of alert fatigue and to developing solutions that are increasingly adapted to the needs of health care professionals. It would be useful to collect more Canadian data on the actions taken by pharmacists when consulting the therapeutic advisor's alerts in a real-world context.

By taking proactive measures, we can maximize the benefits of these technological tools while looking out for the well-being of pharmacists.

Together, we can reduce the percentage of ignored alerts!

References

1. Allison B McCoy, Lemuel R Waitman, Julia B Lewis, Julie A Wright, David P Choma, Randolph A Miller, Josh F Peterson, A framework for evaluating the appropriateness of clinical decision support alerts and responses, Journal of the American Medical Informatics Association, Volume 19, Issue 3, May 2012, Pages 346–352,  https://doi.org/10.1136/amiajnl-2011-000185
2. Bagri H, Dahri K, Legal M. Hospital Pharmacists' Perceptions and Decision-Making Related to Drug-Drug Interactions. Can J Hosp Pharm. 2019 Jul-Aug;72(4):288-294, https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6699872/
3. Miller, L., Pater, K. S., & Corman, S. (2015). The role of clinical decision support in pharmacist response to drug-interaction alerts. Research in Social and Administrative Pharmacy (RSAP), 11 (3), 480-486 https://doi.org/10.1016/j.sapharm.2014.09.005
4. Cuvelier, L. Robert, E. Musy, C. Rousselière, R. Marcilly, S. Gautier, P. Odou, J.-B. Beuscart, B. Décaudin, The clinical pharmacist’s role in enhancing the relevance of a clinical decision support system, International Journal of Medical Informatics, Volume 155, 2021, 104568, ISSN 1386-5056 https://doi.org/10.1016/j.ijmedinf.2021.104568.