Transitioning Ineffective Medications on Hold Alert from Interruptive to Noninterruptive Alert to Decrease Alert Burden

Abstract

Background

Interruptive clinical decision support (CDS) alerts are intended to improve patient care, but can contribute to alert fatigue, diminishing their effectiveness. The alert demonstrated minimal clinical effect while contributing significantly to alert fatigue.

Objective

This study aims to evaluate if transitioning a high-firing medication on hold alert from interruptive to noninterruptive would change provider practices.

Methods

The alert was triggered when at least two medications were held for >48 hours. A pre–post intervention cohort study was conducted to evaluate transitioning the medication on hold alert from interruptive to noninterruptive. A comparison was made to evaluate provider practices in resuming medications during the 6 months before and after transitioning the alert. Data were extracted from the medication administration record and the institutional risk reporting system.

Results

After transitioning to a noninterruptive alert, the number of actions taken by clicking on the alert decreased from 33,632 (3.0 clicks per hospital encounter) to 305 (0.02 clicks per hospital encounter) in a 6-month period. There was no significant change in the median hold duration of medications that were on hold for greater than 48 hours (81.5 hours and 85.6 hours in the pre- and postintervention cohorts, respectively [p-value = 0.22]). There was no change in the most frequent medications that were held until patient discharge, and there was no increased reporting of medication-on-hold safety events.

Conclusion

The initial interruptive medication on hold alert was not effective and contributed to a high volume of alerts in our institution. Transitioning the medications on hold alert from an interruptive to a noninterruptive alert reduced potential alert fatigue without significantly impacting clinical outcomes. These findings highlight the need for careful evaluation of CDS alerts to balance clinical utility and provider alert burden. Alerts that do not affect the desired clinical outcome should be redesigned or retired.

Keywords

clinical decision support - alert fatigue - noninterruptive alerts

Protection of Human and Animal Subjects

The University of Iowa IRB determined this project to be non-human subject research.

Publication History

Received: 13 January 2025

Accepted: 10 June 2025

Accepted Manuscript online:
16 June 2025

Article published online:
13 August 2025

• References

• 1 Blecker S, Austrian JS, Horwitz LI. et al. Interrupting providers with clinical decision support to improve care for heart failure. Int J Med Inform 2019; 131: 103956
• 2 Jaspers MW, Smeulers M, Vermeulen H, Peute LW. Effects of clinical decision-support systems on practitioner performance and patient outcomes: a synthesis of high-quality systematic review findings. J Am Med Inform Assoc 2011; 18 (03) 327-334
• 3 Varghese J, Kleine M, Gessner SI, Sandmann S, Dugas M. Effects of computerized decision support system implementations on patient outcomes in inpatient care: a systematic review. J Am Med Inform Assoc 2018; 25 (05) 593-602
• 4 Chaparro JD, Beus JM, Dziorny AC. et al. Clinical decision support stewardship: Best practices and techniques to monitor and improve interruptive alerts. Appl Clin Inform 2022; 13 (03) 560-568
• 5 McGreevey III JD, Mallozzi CP, Perkins RM, Shelov E, Schreiber R. Reducing alert burden in electronic health records: State of the art recommendations from four health systems. Appl Clin Inform 2020; 11 (01) 1-12
• 6 Simpao AF, Ahumada LM, Desai BR. et al. Optimization of drug-drug interaction alert rules in a pediatric hospital's electronic health record system using a visual analytics dashboard. J Am Med Inform Assoc 2015; 22 (02) 361-369
• 7 Orenstein EW, Kandaswamy S, Muthu N. et al. Alert burden in pediatric hospitals: A cross-sectional analysis of six academic pediatric health systems using novel metrics. J Am Med Inform Assoc 2021; 28 (12) 2654-2660
• 8 Kandaswamy S, Williams H, Thompson SA, Dawson TE, Muthu N, Orenstein EW. Realizing the full potential of clinical decision support: Translating usability testing into routine practice in health care operations. Appl Clin Inform 2024; 15 (05) 1039-1048
• 9 Justinia T, Qattan W, Almenhali A, Abo-Khatwa A, Alharbi O, Alharbi T. Medication errors and patient safety: Evaluation of physicians' responses to medication-related alert overrides in clinical decision support systems. Acta Inform Med 2021; 29 (04) 248-252
• 10 Bittmann JA, Haefeli WE, Seidling HM. Modulators influencing medication alert acceptance: An explorative review. Appl Clin Inform 2022; 13 (02) 468-485
• 11 Carroll AE. Averting alert fatigue to prevent adverse drug reactions. JAMA 2019; 322 (07) 601
• 12 Trinkley KE, Blakeslee WW, Matlock DD. et al. Clinician preferences for computerised clinical decision support for medications in primary care: a focus group study. BMJ Health Care Inform 2019;26(01):0
• 13 Pevnick JM, Li X, Grein J, Bell DS, Silka P. A retrospective analysis of interruptive versus non-interruptive clinical decision support for identification of patients needing contact isolation. Appl Clin Inform 2013; 4 (04) 569-582
• 14 Blecker S, Pandya R, Stork S. et al. Interruptive versus noninterruptive clinical decision support: Usability study. JMIR Hum Factors 2019; 6 (02) e12469
• 15 Steitz BD, Li G, Wright A, Dunworth B, Freundlich RE, Wanderer JP. Non-interruptive clinical decision support to improve perioperative electronic positive patient identification. J Med Syst 2022; 46 (03) 15
• 16 Knake LA, Asbury R, Penisten S. et al. Successfully transitioning an interruptive alert into a noninterruptive alert for central line dressing changes in the neonatal intensive care unit. Appl Clin Inform 2024; 15 (05) 965-969
• 17 Murad DA, Tsugawa Y, Elashoff DA, Baldwin KM, Bell DS. Distinct components of alert fatigue in physicians' responses to a noninterruptive clinical decision support alert. J Am Med Inform Assoc 2022; 30 (01) 64-72