Special Issue on CDS Failures: Transitioning an Ineffective Medications On Hold Alert from Interruptive to Non-Interruptive to Decrease Alert Burden

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: To evaluate if transitioning a high-firing medication on hold alert from interruptive to non-interruptive 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 non-interruptive. A comparison was made to evaluate provider practices in resuming medications during the six months before and after transitioning the alert. Data was extracted from the medication administration record and the institutional risk reporting system. Results: After transitioning to a non-interruptive alert, the number of any 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 six-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 post-intervention 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. Conclusions: 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 non-interruptive 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 don’t affect the desired clinical outcome should be redesigned or retired.

Publication History

Received: 13 January 2025

Accepted after revision: 10 June 2025

Accepted Manuscript online:
16 June 2025