Alert override as a habitual behavior – a new perspective on a persistent problem

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Abstract

Quantifying alert override has been the focus of much research in health informatics, with override rate traditionally viewed as a surrogate inverse indicator for alert effectiveness. However, relying on alert override to assess computerized alerts assumes that alerts are being read and determined to be irrelevant by users. Our research suggests that this is unlikely to be the case when users are experiencing alert overload. We propose that over time, alert override becomes habitual. The override response is activated by environmental cues and repeated automatically, with limited conscious intention. In this paper we outline this new perspective on understanding alert override. We present evidence consistent with the notion of alert override as a habitual behavior and discuss implications of this novel perspective for future research on alert override, a common and persistent problem accompanying decision support system implementation.

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Most cited references 19

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Overriding of drug safety alerts in computerized physician order entry.

Heleen van der Sijs, Jos Aarts, Arnold Vulto … (2005)

Many computerized physician order entry (CPOE) systems have integrated drug safety alerts. The authors reviewed the literature on physician response to drug safety alerts and interpreted the results using Reason's framework of accident causation. In total, 17 papers met the inclusion criteria. Drug safety alerts are overridden by clinicians in 49% to 96% of cases. Alert overriding may often be justified and adverse drug events due to overridden alerts are not always preventable. A distinction between appropriate and useful alerts should be made. The alerting system may contain error-producing conditions like low specificity, low sensitivity, unclear information content, unnecessary workflow disruptions, and unsafe and inefficient handling. These may result in active failures of the physician, like ignoring alerts, misinterpretation, and incorrect handling. Efforts to improve patient safety by increasing correct handling of drug safety alerts should focus on the error-producing conditions in software and organization. Studies on cognitive processes playing a role in overriding drug safety alerts are lacking.

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Habit, Attitude, and Planned Behaviour: Is Habit an Empty Construct or an Interesting Case of Goal-directed Automaticity?

Bas Verplanken, Henk Aarts (1999)

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Overrides of medication alerts in ambulatory care.

Thomas Jesudason Barney Isaac, Michael Massagli, Saul N Weingart … (2009)

Electronic prescribing systems with decision support may improve patient safety in ambulatory care by offering drug allergy and drug interaction alerts. However, preliminary studies show that clinicians override most of these alerts. We performed a retrospective analysis of 233 537 medication safety alerts generated by 2872 clinicians in Massachusetts, New Jersey, and Pennsylvania who used a common electronic prescribing system from January 1, 2006, through September 30, 2006. We used multivariate techniques to examine factors associated with alert acceptance. A total of 6.6% of electronic prescription attempts generated alerts. Clinicians accepted 9.2% of drug interaction alerts and 23.0% of allergy alerts. High-severity interactions accounted for most alerts (61.6%); clinicians accepted high-severity alerts slightly more often than moderate- or low-severity interaction alerts (10.4%, 7.3%, and 7.1%, respectively; P < .001). Clinicians accepted 2.2% to 43.1% of high-severity interaction alerts, depending on the classes of interacting medications. In multivariable analyses, we found no difference in alert acceptance among clinicians of different specialties (P = .16). Clinicians were less likely to accept a drug interaction alert if the patient had previously received the alerted medication (odds ratio, 0.03; 95% confidence interval, 0.03-0.03). Clinicians override most medication alerts, suggesting that current medication safety alerts may be inadequate to protect patient safety.