The tradeoffs between safety and alert fatigue: Data from a national evaluation of hospital medication-related clinical decision support

J Am Med Inform Assoc. 2020 Aug 1;27(8):1252-1258. doi: 10.1093/jamia/ocaa098.


Objective: The study sought to evaluate the overall performance of hospitals that used the Computerized Physician Order Entry Evaluation Tool in both 2017 and 2018, along with their performance against fatal orders and nuisance orders.

Materials and methods: We evaluated 1599 hospitals that took the test in both 2017 and 2018 by using their overall percentage scores on the test, along with the percentage of fatal orders appropriately alerted on, and the percentage of nuisance orders incorrectly alerted on.

Results: Hospitals showed overall improvement; the mean score in 2017 was 58.1%, and this increased to 66.2% in 2018. Fatal order performance improved slightly from 78.8% to 83.0% (P < .001), though there was almost no change in nuisance order performance (89.0% to 89.7%; P = .43). Hospitals alerting on one or more nuisance orders had a 3-percentage-point increase in their overall score.

Discussion: Despite the improvement of overall scores in 2017 and 2018, there was little improvement in fatal order performance, suggesting that hospitals are not targeting the deadliest orders first. Nuisance order performance showed almost no improvement, and some hospitals may be achieving higher scores by overalerting, suggesting that the thresholds for which alerts are fired from are too low.

Conclusions: Although hospitals improved overall from 2017 to 2018, there is still important room for improvement for both fatal and nuisance orders. Hospitals that incorrectly alerted on one or more nuisance orders had slightly higher overall performance, suggesting that some hospitals may be achieving higher scores at the cost of overalerting, which has the potential to cause clinician burnout and even worsen safety.

Keywords: burnout; computerized physician order entry; electronic health record; patient safety; quality of care.

Publication types

  • Research Support, U.S. Gov't, P.H.S.

MeSH terms

  • Alert Fatigue, Health Personnel*
  • Decision Support Systems, Clinical*
  • Electronic Health Records
  • Health Care Surveys
  • Hospitals*
  • Humans
  • Medical Order Entry Systems*
  • Patient Safety
  • Quality of Health Care
  • United States