Optimizing the use of computer system clinical alerts

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PROBLEM: Many of today's computerized pharmacy systems provide vendor-defined and user-defined alerts that remind or warn staff about potential drug-related problems during order entry. Research shows that adverse drug events are vastly reduced where such systems are employed (Bates DW et al. JAMA 1998; 280:1311-16). ISMP often recommends computerized alerts as a way to remind staff about potential problems. However, clinicians and managers have expressed concern that the sheer number of warnings that appear on the screen during order entry can be overwhelming and slow order entry. In many cases, clinically insignificant warnings are as likely to appear as those that are vital. As a result, staff may inadvertently bypass even critical warnings, especially when the workload is high. This is easy to do with many systems. As noted in our February 10, 1999, survey on computer systems, all too often it simply requires striking the "enter" key. If the system forces a response to the warning, practitioners who feel pressured to speed order entry may select the first reason listed on the screen for bypassing the alert, instead of appropriately addressing the issue. Even when practitioners are properly alerted to a potential allergic reaction or harmful drug interaction, they may erroneously assume that the prescriber is already aware of the problem and fail to alert him/her directly.

SAFE PRACTICE RECOMMENDATION:When practitioners become accustomed to unimportant or clinically irrelevant warnings, they often ignore these "false alarms," or turn them off - at least mentally. Fortunately, there are strategies that can be used to optimize the effectiveness of alerts and minimize the possibility of overlooking the more significant ones. First, a tiered system for interactive warnings should be used to allow staff to view and easily bypass less serious issues if appropriate, but require staff to make a text entry to describe the response to more significant alerts. A regularly updated list of significant alerts that require direct prescriber notification can help guide the most appropriate response. Consider asking pharmacists who enter orders to note warnings that they feel are not clinically significant. Then, evaluate the safety of altering the severity level of these less significant warnings to minimize potential for overlooking more clinically significant warnings. Some organizations have adjusted their systems so that only high severity level drug interaction warnings appear. However, the drug interaction leveling system used by one information vendor is based upon the volume of clinically documented cases, rather than the potential for patient harm. Therefore, vendors should be contacted before such a change is made. More significant alerts should be as visible as possible. Some systems may allow large screen fonts in a contrasting color, flashing messages, or other means of distinguishing the alert. Also review non-interactive pop-up messages on an ongoing basis, such as the ones we suggest for avoiding drug name mix-ups. Delete any that are no longer applicable. Consider applying auxiliary labels to drug packages and storage bins to warn about unclear or confusing labeling and packaging, instead of using messages in the computer system. Also consider printing warnings on drug labels and MARs instead of building alerts into the order entry process. For example, print "IM Use Only' warnings on drug labels and MARs for all drugs that can be administered safely by this route only (see a list of commonly-used "IM Use Only" drugs on our web site). Many systems are capable of providing reports about all warnings that have been overridden. Assign a clinician or manager to review the report daily to identify any problems. Consider focusing on one or two common but critically important warnings to monitor the effectiveness of the computer's alert system and the response to the alert. We are interested in learning about any other strategies that have been taken in your facility to optimize the use of your computer warning system. Please contact us by e-mail (ismpinfo@ismp.org) with your suggestions so we can share them with others.