Pre-Empting Bad Publicity with Patient Safety Alerts

If you don't want to be the next negative healthcare headline, then perhaps you should consider implementing patient safety alerts.

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To say that medical errors is bad for public relations is like saying that sugar is bad for a diabetic.

It’s an obvious truism. Highlighting this fact is that, over the last six months, five hospitals have found themselves in the white-hot media spotlight after one or more medical errors occurred at their institutions.

The list includes Kent Hospital in Warwick, Rhode Island, and the prestigious Boston Children’s Hospital in Massachusetts.

After experiencing four separate surgical and procedural errors in a six-month span, Kent Hospital entered into a consent agreement with the state health department to spend at least $1.7 million on a 100-day “turnaround plan” to improve patient safety.

At Boston Children’s, three patients suffered from medication errors, including one patient who waited 14 hours for an antibiotic and later died after developed sepsis. The hospital avoided CMS discipline by implementing a 63-page sepsis improvement plan, in which the hospital said it recognized “the need to focus additional attention in our responses to specific events,” including “the potential of a similar event occurring in another area.”

The Need to Reduce the Number of Low-Value Alerts

Certainly, everyone believes that patient safety alerts can improve health outcomes. But first, we must differentiate between ineffective alerts and effective alerts. As electronic health records (EHRs) have become the norm, hospitals have integrated every imaginable EHR alert into clinical workflows and clinical decision support functionality. While this seems useful, EHR notification overload can become a problem. Low-value alerts can unnecessarily detract from patient care and actually cause more – not less – patient harm.

In fact, The Doctor’s Company – the U.S.’s largest physician-owned medical malpractice insurer – reported that most studies have found that only 20% of alerts are actually accepted, so an important alert could be missed. “Drug-drug interaction lists are often so comprehensive and generate alerts with such frequency that they can become disruptive and annoying,” the company wrote.

However, we don’t need to live in a healthcare world in which 80% are discarded as seemingly low-value, ineffective alerts. In an article published in EHR Intelligence, author Kate Monica wrote, “effective EHR alerts such as admission, discharge, and transfer (ADT) notifications or screening reminders can help to streamline clinical efficiency and care coordination by quickly communicating critical patient information to providers through the EHR interface.”

This includes notifications and alerts to keep different care teams updated during times of admission, discharge, and transfer to improve care coordination and reduce hospital readmissions, as well as notifications about patient status updates, care delivery, medication contraindications, and guideline recommendations.

Alerts to Reduce Unnecessary Tests

While most EHR alerts provide warnings, prompting a provider to take action, some hospitals are using alerts to suggest the opposite. This was the idea behind the Choosing Wisely Campaign, which was launched by the American Board of Internal Medicine (ABIM) Foundation and Consumer Reports in 2012. The goal was to implement alerts – the program targeted five tests or procedures that are frequently ineffectual – that not only help improve patient safety, but also cut down on unnecessary testing and procedures and save providers time.

Several California hospitals – including Cedars-Sinai Medical Center in Los Angeles – took part in the initiative and attempted to reduce instances of patient harm and unnecessary testing through slight changes to their EHRs. The EHR alerts notified physicians electronically when ordering tests or drugs that did not align with 18 Choosing Wisely recommendations embedded into the software. In the study, Cedars-Sinai analyzed alerts from 26,424 patient encounters between 2013 and 2016. All Choosing Wisely guidelines were followed in 6% of those cases, or 1,591 encounters.

In groups that did not comply with Choosing Wisely guidelines, patients had a 14% higher rate of readmission and a 29% higher risk of complications.

Strategies for Reducing Alert Hazards

While patient safety alerts can reduce preventable patient harm and save lives, if mishandled, they can be the precursor to a patient harm event instead. To that end, The Doctor’s Company offers seven strategies for reducing alert hazards that bear repeating. They are:

  • Understand alarm fatigue. When caregivers become overwhelmed, distracted, or desensitized to an alarm or an alert, determine the most important alarms, and work with your vendor to ensure that unnecessary alarms or alerts are not built into your system.
  • Determine if alerts are appropriately configured so that alert conditions are not missed or ignored.
  • Assess your EHR for frequent drug-drug interaction alerts, which have been shown to lead to alert fatigue that can cause the alerts to be disregarded, ignored, or disabled. Work with your EHR vendor to use key data elements to design EHR alerts for high-risk drug-to-drug interactions. The result will be more meaningful alerts that are less likely to be ignored or disabled, thus avoiding a possible error.
  • Be aware that clicking through drug-to-drug therapeutic duplicates or drug/allergy alerts with little review can be interpreted to mean that the physician ignored the safety alerts.
  • Read the alerts. EHRs record how much time is spent reviewing information. If the time is very brief and there is a negative patient outcome, the physician could be perceived as sloppy or hurried.
  • Don’t turn off alerts. If a hospital-employed physician and hospital turn off alerts that could have avoided a patient problem, the hospital and physician may both be found liable.
  • Always document why a clinical decision support (CDS) prompt was overridden. CDS may conflict with a medical specialty’s clinical standards of care or practice guidelines or with the information in FDA-approved drug labels.

Following these tips may not keep your hospital out of the media spotlight, but they are likely to reduce the odds of a patient safety mishap from occurring at your healthcare organization. And if a single instance of preventable patient harm is avoided, then the progress we’ll have made is substantial.

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