WhiteCoat

Alarm Fatigue

Alarm Clock (Copy)For those of you who don’t know what alarm fatigue is, think of a car alarm. The first time you hear it going off, you run to your window to see who’s breaking into a car. Maybe you run to the window the second time and the third time, too. By the tenth time the alarm goes off, you’re thinking that the alarm is broken and someone needs to get that fixed. After about thirty false alarms, you’re feeling like going out there and busting up the car yourself – especially if the car alarm wakes you when you’re asleep.

So alarms can be good, but if there are too many “false positives” – in other words if they go off too much when nothing is wrong – people tend to become tired of listening to them and eventually ignore the alarms.  On the other hand, if there are too many “false negatives” – meaning that they don’t go off when something is wrong – then the alarms aren’t fulfilling their purpose.

The same problem holds true for multiple types of alarms. Think about virus alerts on your computer. If they are set to alert you about everything, the first few times you freak out, then, after investigating, you dismiss them. If they alerts keep occurring too often, eventually you figure out a way to disable them. If the alarms don’t alert you when a virus is trying to hack into your computer … then what good is it to have the software?

With electronic medical records, medical providers are often alerted to multiple types of medical problems with each patient. No recent tetanus shot. Haven’t asked whether the patient is abused at home. No allergy information available yet. Time that patient was first evaluated not entered. Did you review vital signs? The list seems endless sometimes. Some of these alerts are useful. Most just serve to document some government mandated question that we must answer in order to receive payment for billing or to look like we provide better care on some database that only hospital administrators and reporters ever look at.

It was busy as heck during a shift and I kept getting knocked off task by alarms which are supposed to be helping us. A patient is having an acute heart attack. I try to put in orders for basic treatments and labs. Once I get logged into the patient’s chart, that takes a minute or so. Then, before the system will accept the orders, I get the alerts.
“No medical allergy information had been entered for this patient. Medication orders will be canceled.” The only button to hit is “OK” on that screen. Well, he’s a new patient. So I have to spend another few minutes clicking through a dozen or so screens to tell the computer that the patient has an allergy to sulfa drugs (causing him to have an upset stomach) and to iodine (which gave him a “warm” feeling when he received dye for a CT scan once).

Phew. Close call.

Then I spend another few minutes re-entering all of the medications I want the patient to receive. I have to enter all the medications by hand now instead of clicking on the boxes since the computer system won’t let me enter the same “order set” twice on the same patient.

First, let’s give the patient some aspirin. Everyone knows that’s an important treatment for patients having a heart attack.

Whoops.

Sulfa Allergy Aspirin

Alarm. Now I have to go through a few more screens and enter my password to confirm that I dare to give aspirin to a patient who gets an upset stomach when he takes sulfa medications. Where the connection is … GOK.

Well, I’ve dodged that bullet. Now let’s start an IV so that we can give him some IV fluids and have access to give him other medications if he needs them.

Whoops.

Iodine Allergy Saline

Alarm. Now I have to go through more screens and enter my password to confirm that I dare to give salt water to a patient who felt warm after receiving CT scan dye. Where the connection is … GOK. Salt water contains three things: sodium, chloride, and water.

Now that I’ve averted that disaster … oh yeah, the patient has a history of GI bleeds and was pretty anemic last time he was admitted to the hospital. Let’s get a type and screen on him too, just in case he needs blood.

“Reflex order: Blood transfusion.
“How many units of blood will patient receive?” Um … zero. We’re just doing the preliminary stuff if he should need blood.
“Should patient receive Lasix with blood?” Um … no. We’re not transfusing him yet.
Nevermind. Cancel the blood. Cancel. Cancel. Cancel. Yes, I’m sure I want to do that. Confirm.

OK, now let’s … wait a minute. Where was I? Oh yeah. Trying to take care of the patient having a HEART ATTACK.

In creating a “safe” environment for patients, the medical records have delayed me from providing necessary and time-sensitive care to a patient.
Now imagine going through the same or similar scenario multiple times each shift. Every shift.

Ready to go bust up someone’s car yet?

 

26 Responses to “Alarm Fatigue”

  1. Keith Campbell says:

    The problem is your EMR build. A poor build with poor design decisions leads to lots of frustration. I would recommend taking yoru concerns to your EMR committee and have some of these decisions reviewed.

    • WhiteCoat says:

      Perhaps a problem with build.
      Another issue is that there are competing interests. In the event of a medication-related bad outcome, hospitals want to be able to point to the EMR and state that physicians were warned about the interaction and chose the medication anyway.
      If patients suffer bad outcomes because the EMR slowed up the physician, well that’s the physician’s fault, too. Damn slow doctors.

  2. Crystal says:

    Even tax software has levels of alarms – fatal, severe, warning. Surely tax preparation software is less sophisticated than medical management software?

  3. Joules says:

    In the pharmacy we get pt is allergic to drug x which contains yellow dye, do you want to approve drug y which also contains yellow dye. It can be so frustrating when allergy to drug x was upset stomach.

  4. mslaurie says:

    There needs to be some sort of way of ‘grading’ the ‘allergy’, and having the warning systems respond to that.

    EG
    Level 1 – Anaphalyxis – DO NOT ADMINISTER
    Level 2 – Severe reaction – ONLY ADMINISTER IF NO ALTERNATIVE
    Level 3 – Moderate reaction – CONSIDER ALTERNATIVES
    Level 4 – Minor discomfort/side effects – CONSIDER ALTERNATIVES.

    I’d also design the system – if possible – so your initial input of illness if severe enough (like a freaking heart attack!) would automatically override warnings for level 4 ‘allergies’.

  5. defendUSA says:

    WC,
    What EMR are you using? I could forward this on to a friend who works at a particular company and it could be addressed…

  6. Dan says:

    Just to be clear: the patient could not be given aspirin until you had gone through those screens? You can’t ask a nurse to give the aspirin while you documented it? And if someone came in with big holes in his chest you’d be unable to get him a transfusion until after you’ve clicked through a bunch of screens as well.

    I’m just a programmer, but that seems to be a rather suboptimal workflow. Surely the layers of bureaucratic checks bring their own legal risk, no? If a patient were to die of an MI for want of aspirin because you had too many screens to click through, couldn’t the hospital or EMR company be sued? Or is “it’s policy!” a valid legal defense?

    How can you deal with this stuff without having a stroke yourself?

  7. JustADoc says:

    You cannot give the aspirin because you cannot get the aspirin out of the machine, or the pharmacy cannot deliver it, until the patient is in the computer and the drug is ordered. The PYXIS(the machine in question) is there for our safety to make sure the right drug is given to the right patient at the right time(unless of course that time is urgently).
    And don’t even ask about having some drugs available in a stash outside of the PYXIS. Oh my no. The Marijuana commision had an absolute hair-pulling coniption over that one. IT IS NOT SAFE.

    /off sarcasm

    JustADoc

    JustADoc

    • throckmorton says:

      Dont tell JACHO but there is a stash of aspirin, nitropaste, lasix, zofran and Jelco IV catheters sealed in a ziplock bag in the tank behind the toilet.

    • pat says:

      pyxis has override capabilities that can be set up for specific meds, no order required. easy peasy. also, an entire med station can be set up as a critical override machine. our ED machines were set up as critical override/non-profiled machines. no orders needed to remove meds.

      and..that sounds like crappy software

  8. igloodoc says:

    JC found our stash, and it rained holy poo for 40 days straight. In their language, a plan for corrective action needed to be implemented immediately with followup inspection recommended.

    Next time, we will have to hide the nitro,aspirin, lasix etc in a place they would never look… the patient food trays. Then distract them by leaving a muffin in the beside the nursing computer. You will get cited for that (and we have), but it’s mostly paperwork, not re-education camp.

    My new job is computerized paperwork, with a little patient care on the side.

  9. CodeBlue says:

    Wow. Someone found a worse medical record than Meditech.

  10. pat clyde says:

    There is NO computer existent FASTER than me in ED work.
    Let me ask and say it again:WHY does the ED need *##**!! computers?
    O,yeah,lawyers,chargemasters,JC idiots.
    And I heard Epic is being hauled in on anti-trust class action litigation due to the lemming-like mentality that has signed up 60% USA facilities for Epic program.
    Cannot wait to retire off the ED frontlines.
    Crapola to the max.

  11. LC says:

    And this is why most of the docs i know in that case enter “NKDA” and go on. They then later during admit will let the nurse do the “oh he’s allergic to…” and add it in or pharmacy fixes it.

    Then again, we did a suppression of most alerts for MDs. It only will push those alerts through when pharmacy does verification of the orders.

    I’d push to your IT on suppression of those. They only start alerting docs with allergy levels that are in the ‘significant’ range or cross reactivity (it will flag a carbapenem with PCN allergy… will flag a cephalosporin too).

    There are some tricks we in pharmacy also know- never enter ‘percocet’ or ‘vicodin’ allergy. use only oxycodone or hydrocodone or you’re screwed because it will flag near everything cause of excipient ingredients in the acetaminophen (lactose!)

    good lord.

  12. Sharon says:

    From “Best Care Anywhere” – About VA hospital informatics…”Developed at taxpayer expense, the VistA program is available for free to anyone who cares to download it off the Internet. The link is to a demo, but the complete software is nonetheless available. You can try it out yourself by going to http://www1.va.gov/CPRSdemo/. Not surprisingly, it is currently being used by public health care systems in Finland, Germany, and Nigeria. There is even an Arabic language version up and running in Egypt. Yet VHA officials say they are unaware of any private health care system in the United States that uses the software. Instead, most systems are still drowning in paper, or else just starting to experiment with far more primitive information technologies.” – wonderful system. I do not remember how I ever got along without it.

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