drug nomenclature is completed, the NCVHS should ensure that all vendors incorporate it into their technology software.

Organization of Alerts

Standardizing the organization of alerts in pharmacy database systems, infusion pumps, and decision-support applications is required to reduce alert fatigue. The knowledge bases from which drug-related technologies derive their alerts are often highly inclusive, placing more emphasis on breadth of coverage than on clinical relevancy or severity of adverse events (Reichley et al., 2005). Unless alerts are ranked according to a severity– frequency scale and clinical importance, too many alerts tend to be delivered. The need to override excessive, inappropriate, nonspecified alerts can cause clinicians to miss critical safety alerts or to refuse the application altogether because of disruptions in workflow (van Bemmel and Musen, 1997). By the same token, many overrides are clinically appropriate and do not lead to ADEs (Hsieh et al., 2004).

Several studies have demonstrated improvements in clinician acceptance and reductions in inappropriate alerts through the ranking of alerts for all technologies (Kilbridge et al., 2001; DHA, 2002; Weingart et al., 2003; Shah et al., 2006). For example, a study of CPOE systems conducted by Shah and colleagues (2006) used a three-tiered alert structure:

  • Level 1—alerts of the highest severity (i.e., life-threatening or with the potential to cause permanent damage). Clinicians could not proceed with a prescription without either eliminating the contraindication or responding to specific information requested about the patient.

  • Level 2—alerts of strong severity (i.e., serious, capable of aggravating the patient’s condition). Clinicians could proceed if they provided a reason for an override.

  • Level 3—alerts of significant severity (i.e., important for the clinician to know). Clinicians could view clinical information in the alert, but the alert was noninterruptive.

Rather than using an all-inclusive knowledge base to determine the alerts, the researchers used a subset of only the most clinically relevant contraindications that pertained to the ambulatory care setting. Alerts of moderate to low severity were not included. The result was a significantly higher rate of acceptance among clinicians (67 percent) than that found in other studies (11 percent), although acceptance rates differed substantially by alert type (Weingart et al., 2003; Shah et al., 2006).

Alert fatigue and frequent overrides experienced with infusion pumps and bar code medication administration systems are no different than those



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