Transitioning Ineffective Medications on Hold Alert from Interruptive to Noninterruptive Alert to Decrease Alert...

Area of Science:

• Clinical Informatics
• Patient Safety
• Health Systems Research

Background:

• Interruptive clinical decision support (CDS) alerts aim to enhance patient care but can cause alert fatigue, reducing their effectiveness.
• A specific medication on hold alert was found to have minimal clinical impact while significantly contributing to alert fatigue.

Purpose of the Study:

• To evaluate the impact of transitioning a high-volume, interruptive medication on hold alert to a noninterruptive format on provider practices.
• To assess whether this change affects medication resumption and patient safety events.

Main Methods:

• A pre-post intervention cohort study design was employed.
• Provider practices were compared during the 6 months before and after the alert transition.
• Data on alert interactions, medication hold durations, and safety events were extracted from electronic health records.

Main Results:

• Alert clicks decreased dramatically from 33,632 to 305 after transitioning to a noninterruptive alert.
• No significant change was observed in the median hold duration for medications held >48 hours (81.5 vs. 85.6 hours).
• There were no changes in frequently held medications or reported medication-on-hold safety events.

Conclusions:

• The original interruptive medication on hold alert was ineffective and burdensome.
• Transitioning the alert to a noninterruptive format successfully reduced alert fatigue without compromising clinical outcomes.
• Careful evaluation and redesign of CDS alerts are crucial to balance clinical utility and provider burden.