Using Human Factors to Design and Implement Visual Medication Safety Alerts in Electronic Medical Records

1. Using Human Factors to Design and Implement Visual Medication Safety Alerts in Electronic Medical Records Barbara Duffy Health Care Informatics and Technology DHS 8800 Fall 2010

2. Purpose of Medication Alerts for Healthcare Professionals • Warn healthcare staff about potential errors. • Enable and support better therapeutic decisions. • Warn when interacting drugs are prescribed. • Warn when maximum dosage of a drug is exceeded. • Prevent dangerous adverse drug events. • Warn of drug-drug interactions, therapeutic duplication and allergy. • To serve as a safety net for providers. A review of human factors principles, 2010.

3. About Medication Alerts • There is a lack of acceptance of alerts in clinical information systems. • Physicians override between 49 and 96% of medication alerts. • There is a lack of systematic standardization of medication alerts. • The most significant contributor to overrides are too many low priority alerts. • Little research has focused on how alerts are communicated to the user. A review of human factors principles, 2010; Drug safety alert, 2009; Overriding of drug safety alerts, 2006.

4. Examples of Medication Alerts Alerts must be specific for the user. • For example: Alerts for community pharmacists may include interaction, contraindication, drug duplication, unclear prescription, questionable strength, dosage different from previous prescription, drug dispensed for the first time, incorrect patient data, unusual quantity, allergy. A review of human factors principles, 2010.

5. Alert Fatigue • Excessive alerts can result in overriding recommendations without thought. • Reduce the number of alerts that are not useful to the user. • Incorporate human factors principles into alert design to optimize presentation and minimize alert fatigue. • Socio-technical aspect – consider human interaction between the user and technology. A review of human factors principles, 2010; Understanding handling of drug safety alerts, 2010.

6. About Human Factors • Human Factors is the scientific discipline concerned with the understanding of interactions among humans and other elements of a system, and the profession that applies theory, principles, data, and other methods to design in order to optimize human well-being and overall system performance. Human Factors and Ergonomics Society, n.d. • A review of medical informatics literature found basic human factors principles are often not utilized. A review of human factors principles, 2010.

7. Goals of Integrating Human Factors into Medication Alerts • Improve task performance and patient safety through improved alert design and implementation parameters. • Reduce alert overrides and alert fatigue. • Align alerts to fire within workflow processes to increase effectiveness. • Consistent & unique alerting practice - categories, priorities, placement, colors, shapes, verbiage, exposure, etc. Research-based guidelines, 2002; A review of human factors principles, 2010.

8. Visibility of the Alert Place alerts within the visual field of the user and in order of importance: • Highest priority alerts toward the center of screen that does not require eye movement. • Lower priority alerts in fields detected with eye movement (30 to 80° horizontal viewing angle). • Place alerts in close proximity to the controls and displays relevant to the situation being indicated. Research-based guidelines, 2002; A review of human factors principles, 2010.

9. Visibility of the Alert • The alert must be legible and bright. • Consider size, background contrast, lettering characteristics, content, viewing distance, and length of exposure time. • Position alert to avoid glare and reflection. • Use mixture of upper and lowercase letters. • Dark text on a light background is easier to read. Research-based guidelines, 2002; A review of human factors principles, 2010.

10. Prioritization • Red and orange backgrounds are associated with increased hazard and priority. • Standardized signal words enhance user’s ability to distinguish between severity of priority alerts. Such as: Danger, Warning, and Information. • Place signal words at top of alert. • Use angular and unstable shapes to indicate higher priority and regular shapes indicate lower priority. • Consider colorblind users. Research-based guidelines, 2002; A review of human factors principles, 2010.

11. Information Within the Alert When possible the alert should include: • Signal word indicating priority (Danger, Warning, Information) with statement of nature of hazard. • Instruction how to avoid the danger. • Consequence of what may happen if information is ignored. Also - Present the text in the order of required action. Use bullets instead of continuous text. Validate for clarity and comprehension with the intended user population. Research-based guidelines, 2002; A review of human factors principles, 2010.

12. Timing of Alerts • Type of alert should determine timing of its appearance in the workflow. For example – drug/drug interaction or allergy alert is fired as soon as the physician indicates the name of the new medication to be administered. • An alert fires to remind the physician to order lab work after ordering anticoagulants. A review of human factors principles, 2010.

13. Low Priority Alerts • While more alerts seem safer, alert fatigue shows the opposite to be true. • As low priority alerts are often overridden, consider eliminating them. Perhaps assign to Information category. • Remove alerts that contain no useful information for user. • Alerts can be too sensitive and fire before meaningful safety threshold is exceeded or because data is incorrect or out of date. • Cause increased workload, distraction, and lower performance. Characteristics and consequences of drug allergy alert overrides, 2004.

14. More Recommendations • Alerts tailored to the user are less irritating and less prone to error or override. • Auditory alerts may be valuable in special circumstances and should be considered in combination with some visual alerts. • Provide training & collect data on alert effectiveness. • Use color backgrounds to indicate priority. Understanding handling of drug safety alerts, 2010; Overriding if drug safety alerts, 2006; Characteristics and consequences of drug allergy alert overrides, 2004. Danger Warning

15. REFERENCES About HFES. (n.d.). Human Factors and Ergonomics Society. Retrieved from: http://www.hfes.org/web/AboutHFES/about.html Hsiech, T. C., Kuperman, G.J.,Jaggi, T., Hojnoski-Diaz, P., Fiskio, J., Williams, D.H., Bates, D.W., & Gandhi, T.K. (2004, November - December). Characteristics and consequences of drug alert overrides in a computerized physician order entry system. Journal of American Medical Informatics Association, 11(6), 482-491. Phansalkarl, S., Edworthy, J., Hellier, E., Seger, D.L., Schedlbauer, A., Avery, A.J., & Bates, D.W. (2010). A review of human factors principles for the design and implementation of medication safety alerts in clinical information systems. Journal of American Medical Informatics Association, 17, 493-501. Van derSijs, H., Aats, J., & Berg, M. (2006, March – April). Overriding of drug safety alerts in computerized physician order entry. Journal of American Medical Informatics Association, 13(12), 138-147. Van derSijs, H., van Gelder, T., Vulto, A., Berg, M., & Aats, J. (2010, May). Understanding handling of drug safety alerts: a simulation study. International Journal of Medical Informatics, 79(5), 361-369. Wogalter,M.S., Conzola, V.C., & Smith-Jackson, T.L. (2002). Research-based guidelines for warning design and evaluation. Applied Ergonomics, 33, 219-230.