CXO

Alert fatigue: Lessons from the delivery room

Pat Gray recently welcomed a new baby. He also witnessed the burden of alert fatigue first hand at the hospital. Here's what he learned.

Image: iStock/NadyaSabeva

My wife and I just celebrated the birth of our third child— mom and baby are both doing well two weeks after the event. Like many in the technology and consulting fields, I was interested to observe the various processes and technologies involved in my wife's care, especially since we were at the same hospital where our other two children were born three and six years ago. One of the most dramatic changes was that the nursery— the room so commonly seen in movies and on commercials with big windows and rows of babies— was closed. The babies are now left with their mothers for all checkups and no longer spend time there.

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Otherwise, despite a rapid evolution in technology over the past six years and the emergence of mandatory electronic medical record systems, little had changed in the productive use of technology. Sure, there was a terminal in every room, and each visit by a nurse required several minutes of pecking at keys, but one of the obvious frustrations of our past visits remained: machines beeping and displaying alerts that were promptly ignored or bypassed.

An alarming situation

My wife's IV machine was perhaps the biggest culprit, constantly beeping when out of fluid, low on battery, or otherwise upset. I'd usually have to find someone to satiate the machine's demands for button presses, and as I took an occasional walk to stretch my legs, I heard the same unacknowledged beeps emanating from other rooms. Intriguingly, the Joint Commission, a non-profit that accredits hospitals, has concluded that hospital workers often develop alarm fatigue, and tend to ignore the beeps due to the number of false alarms. This causes workers to overlook alarms that indicate a true emergency, a situation that has resulted in 138 reported deaths over a five-year period.

Consider the alarms the average worker at your company is exposed to on a daily basis. I counted a dozen emails from last week demanding URGENT ATTENTION in the subject line, not to mention dozens of reports and ACTION REQUIRED items. Like many leaders, not an insignificant portion of each week is dedicated to interpreting this mass of critical data to determine what is actually relevant. Like everyone, I've surely missed a truly critical message or two amidst the sea of nonsense.

The power of interpretation

One interesting situation I observed involved the nurse in the Labor and Delivery wing. We came to the hospital proactively since the baby was past due. My wife was connected to all the monitoring equipment and told to try and get some rest before being induced into delivery the next morning. Around 3 a.m., she was growing uncomfortable, and the nurse arrived to check on her. She mentioned that she noticed the data from one of the monitors indicated she was restless and getting up frequently, despite the fact that this particular monitor was not meant to convey this type of data. About an hour later our baby was born, making the nurse's appearance incredibly timely and helpful, since we never had to summon anyone, and an extra measure of reassurance and assistance arrived just when it was needed most.

In technology circles, we can be guilty of assuming the quantity of information is an indicator of quality. If we have a dozen financial reports, we often assume that must be better than two or three. However, in an era largely characterized by the corporate equivalent of alarm fatigue, a well-interpreted alert that's delivered proactively is significantly more effective than a dashboard with a dozen metrics, graphs, and statuses. As IT leaders, not only can we be the providers of streamlined, effective information, but also help interpret the information we produce or repurpose noisy reporting tools to allow the right people to make the right decisions.

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About Patrick Gray

Patrick Gray works for a global Fortune 500 consulting and IT services company and is the author of Breakthrough IT: Supercharging Organizational Value through Technology as well as the companion e-book The Breakthrough CIO's Companion. He has spent ...

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