When an Alert is Not an Alert: A Pilot Study to Characterize Behavior and Cognition Associated with Medication Alerts

Introduction. Preventable adverse drug events are a significant patient-safety concern, yet most medication alerts are disregarded. Pharmacists encounter the highest number of medication alerts and likely have developed behaviors to cope with alerting inefficiencies. The study objective was to better understand alert override behavior relating to a motivational construct framework. Methods. Mixed-methods study of 10 pharmacists (567 verifications) with eye-tracking observations and retrospective think aloud interviews. Results. Pharmacists spent on average 14 seconds longer verifying orders with alerts than orders without alerts (p<0.001). Verification occurred before alerts were triggered, and no order changes occurred after alerts. Pharmacists reported 62% of alerts as unhelpful and 21% as frustrating. Alert interactions took on average 3.9 seconds. Discussion. Pharmacists anticipate alerts by making appropriate checks and changes before alert prompts. Medication alerts seem to be useful. However, the observed pharmacists' behavior suggests changes in the alert context are needed to match cognition.