The electronic health record issues warnings when, for example, a drug or drug dosage is contraindicated by the patient's medical records. Yet such warnings are so frequent-and also frequently inappropriate-that many clinicians largely ignore them, a phenomenon known as "alert fatigue."

A study at Brigham and Women's Hospital in Boston, for example, published in the June Drug Safety, found that clinicians were getting one alert for every two medication orders, and were overriding 98% of them.

Another consequence of alert fatigue is the missed opportunity to improve patient care, as illustrated in a recent study in the Journal of the American Geriatrics Society. The researchers set out to measure the efficacy of an alert to encourage deprescribing anticholinergic drugs in older adults because of their link to dementia. The alert not only flagged the problem but also suggested alternative medications. When researchers later compared the medical records of patients who were the subjects of the alert to a control group, they found that 85% of the alerts sent to providers and 95% of those sent to medical assistants went unread, thereby negating their educational value.

Efforts are underway to reduce the quantity and improve the quality of alerts, though as yet there is no consensus on how to do so. One approach, as noted in the Yearbook of Medical Informatics, is to customize alerts with specific patient data, thereby reducing the volume of irrelevant alerts. Alerts could also be tiered and presented differently by order of severity. Some health systems are pressing ahead with redesigns that incorporate clinician preferences. "Without system redesign," warned the Agency for Healthcare Research and Quality's Patient Safety Network, "the safety consequences of alert fatigue will likely become more serious over time."-Frank Brodhead