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Appl Clin Inform 2025; 16(04): 988-994
DOI: 10.1055/a-2661-3670
Case Report

Sisyphus' Alert: The Uphill Struggle to Improve Venous Thromboembolism Prophylaxis Clinical Decision Support

Emily E. Schildt
1   Department of Pediatrics, University of Washington, Seattle, Washington, United States
2   Department of Biomedical Informatics and Medical Education, University of Washington, Seattle, Washington, United States
3   Information Technology Services, UW Medicine, Seattle, Washington, United States
,
Paul R. Sutton
2   Department of Biomedical Informatics and Medical Education, University of Washington, Seattle, Washington, United States
3   Information Technology Services, UW Medicine, Seattle, Washington, United States
4   Department of Medicine, University of Washington, Seattle, Washington, United States
,
Andrew F. Lees
5   Health Services Administration, Los Angeles Department of Health Services, Los Angeles, California, United States
,
Hasan B. Ahmad
6   Information Systems Administration, Parkview Health, Fort Wayne, Indiana, United States
,
Albert C. Lee
7   Department of Medical Informatics, Washington Permanente Medical Group, Seattle, Washington, United States
,
Michael G. Leu
1   Department of Pediatrics, University of Washington, Seattle, Washington, United States
2   Department of Biomedical Informatics and Medical Education, University of Washington, Seattle, Washington, United States
3   Information Technology Services, UW Medicine, Seattle, Washington, United States
8   Seattle Children's Information Technology Department, Seattle Children's Hospital, Seattle, Washington, United States
9   Department of Family Medicine, University of Washington, Seattle, Washington, United States
,
Patrick Wedgeworth
2   Department of Biomedical Informatics and Medical Education, University of Washington, Seattle, Washington, United States
4   Department of Medicine, University of Washington, Seattle, Washington, United States
,
Andrew A. White
3   Information Technology Services, UW Medicine, Seattle, Washington, United States
4   Department of Medicine, University of Washington, Seattle, Washington, United States
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Abstract

Background

Chemoprophylaxis reduces the risk of hospital-acquired venous thromboembolism (VTE), but is not reliably ordered. Our institution created a clinical decision support (CDS) interruptive alert to remind clinicians to order VTE chemoprophylaxis when it is missing for qualifying inpatients. Unfortunately, this alert has required repeated modifications to ensure accurate logic, and continues to generate negative feedback from users.

Objectives

This study aimed to describe multiple failures in the development and postdeployment optimization of this interruptive alert, and our lessons learned.

Methods

This study analyzed the number of times this alert fired over 6 months of testing and 16 months of deployment, and changes in either the frequency of alert firing or the frequency of the alert being dismissed without orders placed with iterative changes in the alert logic. Feedback about this alert was compiled and classified into common themes.

Results

The initial alert fired an average of 11,154 times per week when tested silently, prompting significant refinements before release. The alert shown to users fired an average of 53.8 times per 1,000 patient days in the first 6 months of the study period. Despite postlaunch improvements, this rose to 61 alerts per 1,000 patient days in the final 6 months of the study. Modifications also did not cause a significant decrease in how frequently the alert was dismissed without further action being taken (88%). Review of narrative feedback and its classification highlights “wrong person” receiving the alert being by far the most prevalent cause for negative submitted user feedback (nearly 50%), despite efforts to develop logic that limits firing to the patient's primary team.

Conclusion

Changes to this VTE alert were summarized as failures to meet the “five rights” of CDS. Alerts for high-priority safety issues require persistent feedback-driven improvement, particularly when there is poor performance or negative user experience.

Keywords

clinical decision support - alerting - alert fatigue - satisfaction - safety

Protection of Human and Animal Subjects

The Institutional Review Board has reviewed and deemed this “not human subjects research.”


Supplementary Material



Publication History

Received: 03 December 2024

Accepted: 20 July 2025

Article published online:
03 September 2025

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