Eyeworld

8 Ophthalmology Business • September 2017 now ricocheted back to the pharma- cy, having been signed and validated by a licensed physician." The number of pills, dispensed by a pharmacy robot (Dr. Wachter's article pointed out that a human dispensing the pills might have found something off about it and raised a question) and administered by a nurse who only had experience giving the antibiotic as a liquid or intravenously, meant the full pre- scription was taken by the patient. As a result of the 39-fold overdose, the patient had a grand mal seizure and stopped breathing, but he lived. Dr. Rao said he can see how alert fatigue could lead to physicians inad- vertently ignoring an important alert among the other noise. "I may see an alert like this five to 10 times a day, and usually I quickly click it away. However, occa- sionally some alerts can be useful, for instance an alert indicating that a pa- tient has an allergy to fluoroquinolo- nes when I am entering the order for ofloxacin, which I use for almost all my cataract surgery patients. Because I am so used to quickly bypassing the irrelevant alerts and have figured out exactly what to click to make the alerts go away, I could potentially miss the valid alert indicating a med- ication allergy," Dr. Rao said, adding that while it hasn't happened yet, it could, "and that stresses me out." Reforming the system Dr. Boland said Wilmer Eye Institute has been working to minimize alerts for more than a decade. "There has to be a compelling reason to turn one on, otherwise we don't configure them to appear," he said. "Considering adding an alert is a balancing act between 'What is the risk of not warning somebody vs. the burden of having these pop up every 20 minutes during the day?'" Dr. Impact on the patient Dr. Boland said he can't recall any reports at Wilmer where alert fatigue has been implicated in an adverse patient event. According to the Patient Safety Network of the Agency for Healthcare Research and Quality, "there are few studies that quan- tify adverse events related to alert fatigue." The Boston Globe, however, found in an investigation that there were more than 200 patient deaths in hos- pitals across the country from June 2005 through June 2010 that resulted from unheeded alarms on patient monitors. 4 Robert Wachter, MD, University of California, San Francisco, wrote a book—The Digital Doctor: Hope, Hype, and Harm at the Dawn of Medicine's Computer Age, which was excerpted in the digital magazine Backchannel in 2015—that reported a specific and extreme example of how alert fatigue severely impacted one patient. 5 In it, Dr. Wachter recounted the true story of how in 2013 a 16-year-old with a rare genetic disease was given not one antibiotic pill at the hospital but 38.5 of them. A problem with the default setting in the dose unit in the electronic health system caused the pharmacist to prescribe the dose in milligrams per kilograms (the default used for pediatric patients less than 40 kilograms) instead of milligrams. As one might expect, a pop-up alert was issued when this overdose was entered. As Dr. Wachter put it, "With her task list brimming with dozens of unchecked boxes and more sick kids in need of her care and attention, [the admitting physician] assumed that the alert she received after sign- ing the Septra order was yet another annoying one with no clinical signifi- cance, and so she clicked out of it. With that, the order for 38½ Septras frequency of four times a day. The message requires me to enter some justification before proceeding, so I always enter 'Benefit outweighs risk.' It takes a significant amount of effort to have our EMR analysts suppress these messages, and sometimes it is not possible to do so, since much of the medication data comes from third party vendors, and we have no easy way of contacting them. It's much easier to click away the alert, which just takes a moment, but in aggregate, every extra second and every extra click adds up fast." Dr. Areaux said: "The majority of the time we're prescribing eye drops, they are not having a vast systemic effect. However, eye drops often contain the same generic compounds that are in a lot of other systemic medicines, like blood pres- sure medicines, so they're associated with the same alerts about changing heart rate or blood pressure or cross reactivity with other medications or [a dose that is too high]. There are a lot of pop-ups that we get that are extrapolated from the systemic forms of medication that are often inappli- cable to our clinical situations. We do end up closing and ignoring those regularly." The potentially inapplicable alerts are not only annoying, but they disrupt workflow and thinking, Dr. Areaux said. "Disruptive alerts force you to divert from your current workflow, address them, and then revert back to your workflow. Every time we do that we're disrupting physician thought," he said. "The problem is if we're constantly interrupting good patterns of thinking for useless alerts, people start to click past them faster, and at best we get no benefit. At worst, we may be diverting the physician from something important for the patient, something that could be missed." continued from page 7

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