Background The rapidly increasing computerization of health care has produced benefits for clinicians and patients. Effect of alert fatigue on patient safety Much of the literature on alert fatigue derives from studies of CPOE and clinical decision support systems , in which alerts are provided to warn of potentially harmful drug—drug interactions or incorrect medication doses.
These studies consistently show three main findings: Alerts are only modestly effective at best. A systematic review of computerized reminders found only minor improvements in targeted processes of care, and, while CPOE systems have been shown to markedly decrease prescribing errors, this can largely be ascribed to their ability to standardize drug doses, provide decision support, and eliminate errors from poor handwriting or incorrect transcriptions.
Alert fatigue is common. Clinicians generally override the vast majority of CPOE warnings, even "critical" alerts that warn of potentially severe harm. There is less literature on other types of warnings, but it is likely that rates of overriding or ignoring warnings in other settings are also high. Alert fatigue increases with growing exposure to alerts and heavier use of CPOE systems.
This finding is intuitive, but also raises the important implication that without system redesign, the safety consequences of alert fatigue will likely become more serious over time. Tailor alerts to patient characteristics and critical integrated clusters of physiologic indicators.
For example, incorporate renal function test results into the alert system so that alerts for nephrotoxic medications are triggered only for patients at high risk. Tier alerts according to severity. Warnings could be presented in different ways, in order to key clinicians to alerts that are more clinically consequential.
Make only high-level severe alerts interruptive. Apply human factors principles when designing alerts e. Department of Health and Human Services.
Readers should not interpret any statement in this report as an official position of AHRQ or of the U. None of the authors has any affiliation or financial involvement that conflicts with the material presented in this report. Effect of alert fatigue on patient safety. Impact of a national QI programme on reducing electronic health record notifications to clinicians. Computerised physician order entry-related medication errors: analysis of reported errors and vulnerability testing of current systems.
Insights into the problem of alarm fatigue with physiologic monitor devices: a comprehensive observational study of consecutive intensive care unit patients.
Drug—drug interactions that should be non-interruptive in order to reduce alert fatigue in electronic health records. Impact of non-interruptive medication laboratory monitoring alerts in ambulatory care. January 7, A clinical case of electronic health record drug alert fatigue: consequences for patient outcome. June 12, Failure to utilize functions of an electronic prescribing system and the subsequent generation of 'technically preventable' computerized alerts. July 25, Alcohol may shorten the time to fall asleep, but it disrupts sleep later in the night.
Nicotine also can disrupt sleep and reduce total sleep time. Creation of a program that addresses both workplace and personal factors may include to:. It varies, but on average studies say we need at least 7 to 9 hours every day.
Studies have reported that most night shift workers get about 5 to 7 hours less sleep per week than the day shift. You can accumulate a sleep "debt", but not a surplus. Humans follow an "internal" or "biological clock" cycle of sleep, wakefulness, and alertness.
Although these circadian rhythms are influenced by external clues such as the sun setting and rising, it is the brain that sets your pattern. Most cycles are hours long and there are natural dips or periods when you feel tired or less alert - even for those who are well-rested. If you suspect you may have a medical condition that interferes with your sleep, go to your doctor and have any concerns investigated.
There is no one way to get a good sleep - what works for one person may not work for another. In general, suggestions include:. Our bodies need energy provided by food to be able to perform our daily activities. Having meals at regular times is important to function at our best. If you tend to skip meals or eat at irregular times, you may experience fatigue, food cravings or increased eating at the next meal.
Aim to have at least three meals a day including a variety of foods as described in Canada's Food Guide. A heavy meal during the night may cause heartburn, gas or constipation, as well as make you feel sleepy or sluggish. Having snacks in between meals is a great way to keep us nourished and give us the energy we need to complete our work shifts. At breaks, opt for healthy snacks that include combinations from a variety of foods from the four food groups.
Here are some ideas:. Excessive intake of caffeine can cause insomnia, headaches, irritability and nervousness. Some evidence exists that napping before a long drive may help make up for sleep loss in the short term and enhance wakefulness during the drive. Napping has the greatest effect on performance several hours after the nap Dinges et al. Two other proven interventions avoid known problem situations: not drinking alcohol when sleepy Roehrs et al.
Mitler et al. Graduated driver-licensing programs that disallow late-night driving among younger drivers can mandate this risk-avoiding behavior Waller, ; Frith, Perkins, When a driver becomes drowsy, the most obvious behavioral step for avoiding a crash is to stop driving and sleep for an extended period. When this approach is not practical and another driver is not available to take over, studies have found two remedial actions that can make a short-term difference:.
Taking a break for a short nap about 15 to 20 minutes has been shown to improve subsequent performance, even among sleep-deprived people Horne, Reyner, a; Dinges et al. Naitoh found that short naps every 6 hours during a hour otherwise sleepless period was effective in maintaining performance in the laboratory.
However, nappers are often groggy for about 15 minutes upon awakening from naps longer than 20 minutes Dinges, Practical issues with this strategy include the inability of some people to take short naps and the need for secure rest areas. The New York State survey found that about one-third of drivers had needed or wanted to stop in the past year, but a rest area was not available.
Many also were unlikely to use a rest area when they were driving alone at night. Consuming caffeine. Caffeine, even in low doses, significantly improves alertness in sleepy people but only marginally in those already alert Regina et al. The minimum dose needed can be obtained in about two cups of percolated coffee, although caffeine content of coffee varies widely Fox, Caffeine also is available in other forms such as caffeine-fortified soft drinks and tablets.
In driving simulators, sleep-deprived drivers who consumed caffeine reduced lane deviations, potential crashes, and sleepiness for about an hour after consumption Horne, Reyner, a. Nicotine can improve short-term performance significantly in people with cognitive or attention performance impairments such as those from sleepiness Kerr et al.
Obviously, however, smoking tobacco should not be generally recommended in an educational campaign as a drowsy-driving countermeasure because the well-established risks substantially outweigh the possible benefits.
The panel found no evidence of effectiveness for commonly accepted remedial approaches such as brief exercise e. The panel found no studies evaluating other driver-reported steps such as talking to another passenger, talking on a cellular phone or CB radio, chewing gum or ice, or snacking. One study suggests that talking on a cellular phone while driving is associated with increased crash risk Redelmeier, Tibshirani, Although effective treatments are available for both narcolepsy and obstructive sleep apnea, relief of sleepiness and related symptoms is not always easily achievable for all patients Broughton et al.
Although treatment can improve driving simulator performance Findley et al. A few studies to date have evaluated crash experiences of patients successfully treated for these disorders and found a positive effect Cassel et al. An impediment to diagnosis is a lack of physician education on the recognition of sleepiness and sleep disorders National Commission on Sleep Disorders Research, To date, research has validated only one type of device that alarms or awakens drivers who are drowsy or asleep-shoulder rumble strips placed on high-speed, controlled-access, rural roads.
A recent synthesis of reports on the effectiveness of rumble strips shows that they reduce drive-off-the-road crashes by 30 to 50 percent-the only countermeasure the panel found in any category that has a demonstrated effect on crashes.
Rumble strips also appear to be a relatively low-cost solution with a positive benefit-to-cost ratio Garder, Alexander, ; National Sleep Foundation, June However, the effectiveness of rumble strips has been demonstrated only in drive-off-the-highway crashes; their value with other types of sleepiness or inattention crashes or other types of roads has not been studied.
Section II lists some of the technological in-vehicle monitors designed to detect and evaluate driver sleepiness. Some of these devices contain alarms or other alerting devices that go off when indications of sleepiness occur. Controlled trials are needed to evaluate the usefulness of these tools. An inherent deficiency in all types of alerting devices is that many people continue to drive even when they know they are drowsy and fighting to stay awake.
Although an effective alerting device may prevent one crash, a driver who falls asleep once is likely to fall asleep again unless he or she stops driving. Some safety experts have expressed concern that alerting devices may in fact give drivers a false sense of security, encourage them to drive long after impairment, and inhibit their taking effective behavioral measures to prevent or relieve sleepiness Lisper et al.
Research has shown that effective steps are available for both employers and employees to reduce the likelihood of excessive sleepiness and drowsy driving. Because of the complexity of the issues involved Rosekind et al. Researchers also have found differences in individual tolerance to shift work Harma, ; knowing more about the biological and behavioral factors that determine these differences could provide direction for future educational efforts.
Several approaches have been effective in reducing sleepiness caused by working irregular hours and nighttime hours. To minimize disruption and help employees adjust to circadian rhythm changes, employers should educate employees about the problem Harma, In addition, periods of work longer than 8 hours have been shown to impair task performance and increase crashes.
For example, performance appears worse with a hour, 4-day week schedule than with an 8-hour, 6-day week Brown, In jobs with extended hours, the scheduling of work and rest periods to conform to circadian rhythms promotes better sleep and performance Stampi, Another effective approach is to allow and facilitate napping for night shift workers Dinges, ; Naitoh, Shift workers themselves can take steps to reduce their risks of drowsy driving by planning time and creating an environment for uninterrupted, restorative sleep good sleep hygiene Minors, Waterhouse, ; Rosa, Shift workers who completed a 4-month physical training program reported sleeping longer and feeling less fatigue than did matched controls who did not participate in the program.
However, individual response to the stresses of shift work varies Harma, , and the background factors or coping strategies that enable some workers to adapt successfully to this situation are not well defined. The behavioral steps discussed earlier for younger males also seem reasonable for reducing risk in this population.
Nurses working the night shift reported using white noise, telephone answering machines, and light-darkening shades to improve the quality and quantity of daytime sleep Novak, Auvil-Novak, Several studies show that timed exposure to bright light has been successful in helping shift workers and those suffering from jet lag adapt to and overcome circadian phase disruption Czeisler et al. This approach promotes longer, uninterrupted sleep, which may help reduce sleepiness on the job and behind the wheel.
The panel did not find data linking such treatment to changes in rates of crashes or industrial accidents. Promote shoulder rumble strips as an effective countermeasure for drowsy driving; in this context, raise public awareness about drowsy-driving risks and how to reduce them.
Educate shift workers about the risks of drowsy-driving and how to reduce them. Although males up to age 45 have increased crash risks, the panel targeted only the younger group to enable specific tailoring of educational messages to this population's needs and preferences.
In fact, campaign designers may want to segment further, creating different messages for the to and to age groups. The younger group is high school age and more likely to live at home with parents; members of the older group are more likely to be working or in college, living on their own and less subject to parental authority. The panel also believes it may be worthwhile to educate preteen boys, their parents, and their schools to influence attitudes before problems begin.
The messages might be the following: sleepiness is not inevitable for teens, and it is not okay to drive when you are sleepy.
The panel recognized that the risk-taking behaviors of younger men will be a challenge in developing successful educational approaches. Focus group research is needed to develop a better understanding of young men's perceptions of fall-asleep crash risk and the kinds of interventions that would be effective with this group.
Based on the literature, however, the panel suggests that campaign designers consider the following message points, many of which are appropriate for all public audiences:. Sleepiness is a serious risk for young male drivers. Although little is known about the knowledge and attitudes of this group regarding sleepiness and driving risk, surveys of the general population suggest that knowledge of the risk is likely to be low and awareness will need to be raised.
It also will be important for messages to affect attitudes, so that young men and their parents believe the risk is serious and young men are vulnerable. Misconceptions that sleepiness is inevitable at this age and that chronic sleepiness is a safe lifestyle choice need to be overcome. Under- standing the concept of sleep debt could be useful, as could recognizing the uncontrollable nature of falling asleep at high levels of drowsiness.
Driving between midnight and 6 a. Scheduling a trip at another time is a simple way to reduce risk, especially if the drive is long.
An active lifestyle that restricts sleep is a special risk. Many young men will recognize themselves in the picture of a chronically sleepy student who also works part-time, participates in extracurricular activities, and has an active social life.
The "all nighter" represents an acute risk because extreme tiredness follows one sleepless night. The recommended action is not to start a long drive after one or more sleepless nights e. Drinking alcohol increases sleepiness, and the combination of alcohol and sleepiness decreases performance and increases risk, even at low levels of alcohol use.
A message that would convince young men not to drink when they are already sleepy could be useful. However, focus groups of youth in New York State revealed that drowsy-driving messages could be lost or ignored if paired with "don't drink and drive" messages, which some believe are already overemphasized New York GTSC Sleep Task Force, You can take effective steps if you become sleepy while driving.
These steps include stopping driving altogether, if possible; consuming the caffeine equivalent of two cups of coffee; taking a minute nap, and after the nap, driving to the closest safe resting spot, such as a motel, friend's house, or home; and sleeping.
Successful strategies from drinking and driving campaigns might also be adapted to drowsy driving if focus groups confirm their appeal.
For example, an educational campaign could suggest that teens call a friend or a parent for a ride or let a friend drive home instead of driving while sleepy.
Complementary educational messages to parents might suggest that they tell teenagers to call for a ride at any hour without recriminations if they feel too sleepy to drive.
In another alcohol strategy variation, parents might allow sleepy friends of teens to sleep over rather than drive home. The campaign also could counter common misconceptions of useful "stay awake" behaviors, such as exercising, turning on the radio, or opening the windows, which have not been shown to prevent sleep attacks. Messages to policymakers could promote the value of graduated driver licensing that does not permit younger drivers to drive during late night hours e.
These leaders may need information on the drowsy-driving problem and the special risks of driving during this period for all drivers and especially for younger ones.
The panel believes that focusing a campaign on shoulder rumble strips offers multiple educational opportunities to convey key drowsy-driving messages. What rumble strips are and why they are increasingly being used.
A message that rumble strips are designed to arouse sleepy drivers before they drive off the road could be an attention-getting way to highlight the prevalence of chronic sleepiness and point out the risks and possible consequences of drowsy driving.
People who have driven over a rumble strip in the past could personalize the risk, and even seeing the strips on the highway in the future could repeatedly remind people of the message. What to do when awakened by driving over a rumble strip. Rumble strips act as an alarm clock, alerting drivers to the fact that they are too impaired to drive safely.
The key to safety is what the driver does after hearing the alarm. In the short term, risk-reducing actions include stopping immediately if possible e. Then the driver should get off the road e. In the longer term, planning ahead can help people avoid driving while drowsy. Key steps include planning sleep and naps before long trips, scheduling trips to avoid midnight through 6 a.
The limitations of rumble strips. Rumble strips should not give drivers a false sense of security about driving while sleepy. The strips are useful as alerting devices, but they will not protect drivers who continue to drive while drowsy. Being awakened by driving over a rumble strip is a warning to change sleep and driving behaviors for safety. The strips are not a technological quick fix for sleepy drivers. Messages to policymakers, especially from States in which rumble strips are not currently used, can emphasize what rumble strips are, their relative cost-effectiveness, and why they are a valuable addition to highways in rural areas.
Policymakers also may need information on the risks of drowsy driving and crashes to put the need for rumble strips in perspective. Employers, unions, and shift workers are potential target audiences for education on shift work and drowsy driving issues.
The panel believes that an initial focus on employees would complement and reinforce other drowsy-driving messages directed to the public. Although many shift workers are not in a position to change or affect their fundamental work situation, they and their families may benefit from information on their risks for drowsy driving and effective countermeasures. Key message points include the following:.
Shift work may increase the risk of drowsy-driving crashes. Night-, early morning-, and rotating-shift workers are often sleepy because their work times are inconsistent with the natural sleep-wake cycle. Workers on these shifts routinely get less sleep and lower quality sleep than do day workers.
Driving while sleepy is a risky behavior that leads to many serious crashes each year. Many drowsy-driving crashes occur at this time. Driving while acutely tired, such as after a night shift, also increases the risk of crashing. Shift workers, many of whom are already chronically sleep deprived, are at extra risk.
You can take effective steps to reduce your risks. First, it is important to give regular priority to getting good sleep by creating a quiet, cool, dark environment, allowing sufficient time for sleep, and trying to sleep during the same hours each day.
Another strategy is to avoid driving home from work while sleepy e. Consuming caffeine equivalent to two cups of coffee may help improve alertness for a short period. However, other sponsors can make an important contribution by disseminating messages to high-risk audiences, intermediaries, and gatekeepers, such as industries where shift work is prevalent. Potential sponsors may include consumer, voluntary, health care professional, and industry groups and other government agencies.
The panel encourages such groups to use this report and resulting campaign materials to inform and assist their own audience-specific efforts. Sharon L. Jesse Blatt, Ph. Allan I. Forrest Council, Ph. School of Medicine.
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