Rethinking the Biohazardous Bodily Fluids Alert for Improved Workflow and Safety.

Area of Science:

• Healthcare Informatics
• Patient Safety
• Human-Computer Interaction

Background:

• Clinician exposure to hazardous drugs and bodily fluids poses significant health risks, including carcinogenicity and organ toxicity.
• A prior biohazardous bodily fluids alert in the electronic patient record (EPR) at SickKids was ineffective, with a 0% action rate and significant clinician time wasted.
• Clinician feedback over 42 months indicated frustration and desensitization due to the alert's disruptive nature and high frequency.

Purpose of the Study:

• To redesign a clinical decision support (CDS) system to minimize hazardous bodily fluid exposure risk.
• To reduce alert fatigue experienced by clinicians.
• To improve workflow integration while maintaining critical safety communication.

Main Methods:

• A human-centered design approach was employed to redesign the alert system.
• The interruptive pop-up alert was transformed into a passive notification integrated into the patient's electronic health record (EHR) storyboard.
• Ongoing evaluation and feedback collection guided the redesign process.

Main Results:

• The redesigned passive notification reduced workflow disruptions by allowing clinicians to access hazardous status information non-intrusively.
• The new system effectively balanced the need for safety communication with the demand for efficient clinical workflows.
• The redesign addressed the root cause of alert fatigue by altering the alert's delivery mechanism.

Conclusions:

• Redesigning CDS alerts is crucial for enhancing clinician safety and improving workflow efficiency.
• Passive notifications can be an effective strategy to mitigate alert fatigue while preserving essential safety information.
• Further evaluations are planned to assess the impact on personal protective equipment compliance and clinician burnout.