Reducing Medication Errors by Revamping mCDS Alerting: The Goldilocks Principle

Davies Award of Excellence

In 2018, Northern Light Health transitioned ambulatory clinics to the primary inpatient vendor platform, providing a single, system-wide approach to clinical workflows, and unifying capacity for data analysis, informatics governance, and informatics clinical support.

The capability to review mCDS data at a system-wide level provided insight into overall medication Clinical Decision Support processes. We began a new initiative to enhance patient safety by reducing the degree of alert fatigue, with the expectation that removal of nuisance alerting would positively impact not just the provider EHR experience, but also reduce the overall incidence of medication errors systemwide.

This initiative was powered by robust and consolidated information from our unified system, for the first time allowing us to leverage Northern Light Health system-wide data on medication alert volume, alert overrides, and medication error rates. We partnered with Leapfrog and Cerner to query our system and determine where our alerts were deficient and understand where we could focus our improvement efforts on high-risk clinical scenarios. We brought together hundreds of stakeholders, led by Clinical informatics, and included representation from pharmacy, pharmacy information systems, inpatient practitioners, ambulatory practitioners, specialty practitioners, nursing, and other clinical disciplines.

Leadership by Clinical Informatics allowed the work to be deeply entrenched in Clinical informatics principles, building on pivotal clinical decision support concepts such as “the five rights of effective alerting” and the “10 rules of Clinical Decision Support,” which were reviewed as a group at the start of each meeting.