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Myriad Warnings Blur the Message


A plethora of posters, a load of labels, and a rainbow of colored wristbands confront the average hospitalist every day. They serve as reminders to wash your hands, avoid using an extremity for blood draws, and other warnings both important and not so much. In this day and age, with a multitude of visual and technological reminders confronting physicians, some raise concerns about the consequences of too many reminders, also known as “alert fatigue.”

“The premise of [warning] signs is to improve quality,” says David Grace, MD, FHM, area medical officer for the Schumacher Group in Lafayette, La., and a member of Team Hospitalist. “I am not at all convinced that this is being accomplished. There is so much visual noise [in the hospital] that important messages get lost in the clutter.”

Alert fatigue is most often used to describe a phenomenon seen in computerized decision support systems. It’s the result of a physician receiving so many warnings that they grow numb and stop looking at them. Although it hasn’t been studied to the same extent in the low- or no-tech arena, alert fatigue is an issue in hospital-based signage.

Marilyn Sue Bogner, PhD, chief scientist at the Institute for the Study of Human Error, LLC, in Bethesda, Md., says alert oversaturation can have unintended consequences. “If there are too many signs, you really have no signs because people don’t pay attention,” she says. “I wouldn’t call it information overload, because you have to take information in before you can be overloaded.”

This lack of attention can lead to important information being ignored or misunderstood. It could cause serious disruptions in patient care and adverse outcomes, including the possibility of injury or even death.

Too Much of a Good Thing

One potentially harmful trend of warning signs in the hospital setting is what psychologists call “dilution.” The more warnings there are, the more people tend to lose sight of why the warning is there in the first place, and low-importance warnings “dilute” the strength of important ones.

“I would like to see a system where only truly high-risk patients are the ones who get the warnings,” Dr. Grace says. “If you restricted precautionary signs to those patients at high risk for transmitting something bad, or those at high risk for getting something bad, you would get better adherence than currently, where you seem to have signs for any patient with any risk for transmitting anything.”

For all the visual cues in the hospital setting to warn physicians of potential dangers, there exists no standardized system to help hospitalists sort out the direct patient-threats from the more mundane housekeeping chores.

Pennsylvania Incident Results in Statewide Wristband Standards

Warning indicators often mean different things at different hospitals, another safety concern for hospitalists. In 2005, a traveling nurse in a Pennsylvania hospital put a yellow armband on a patient. At her home facility, a yellow armband meant a “restricted extremity” that was not to be used for blood draws. At the other hospital, it designated “do not resuscitate.”

Fortunately, the mistake was found before it caused harm to the patient. However, the mixup highlighted the concern for consistency. Pennsylvania law requires the reporting of “near miss” errors, even if the patient was not harmed.

The Pennsylvania Patient Safety Authority surveyed hospitals (see Table 1) and found little continuity among respondents, with nine different colors being used to distribute 22 messages. No color was used universally. The percentage of facilities using a standard color for a specific message ranged from 92% utilizing red to indicate blood type to 31% using green for falls.

“We issued an advisory outlining our findings,” authority executive director Michael Doering says. “A group of facilities in the Northeast got together and standardized the usage of the wristbands that later spread to the rest of the state. Since then, 30 states have issued some kind of guidance on standardizing wristband colors based on the initial work done in Pennsylvania.” —KU

Table 1. Variance of Medical click for large versionSource: Pennsylvania Patient Safety Authority

Table 1. Variance of Medical "Messages" and Colors Used on Patient Wristbands in Pennsylvania Hospitals.

“Even a warning that is effective by itself may get buried when there are others hanging around it,” Dr. Bogner says. “There is no hierarchy of importance in most hospitals because there is no central authority making sure that red, for instance, is saved only for a warning about the most dangerous incidents.”

Often specialists are responsible for signs relating to their area of expertise without taking into account the addition to the chaos as well as how the warning will fit in with the realities of the hospital unit. Clutter in the ICU and other areas of the hospital can be exacerbated by multiple disciplines putting up their own signs. There is no method for hospitalists to look around and see which warnings pertain to them.

“There is a reason why all stop signs are red and have eight sides,” Dr. Grace says. “[It] makes it easy to for all to recognize at a glance what is being communicated. In hospitals, the same warning may be many different shapes and colors. This can make it hard for hospitalists, especially those who go to more than one hospital, to know what is being said and the response expected.”

Placement of visual warning signs can add to the confusion and limit effectiveness. Information is best placed near where it is to be used. For example, a sign telling staff that a certain extremity should not be used for blood draws is more likely to be seen and acted upon if it is in the form of a wristband attached to the arm instead of a warning sign on the door. It also is important to have easy access to the tools needed to follow the warning sign’s directions.

“Hospitals don’t have the resources to put a fully stocked isolation cart near every door,” Dr. Grace says. “You get a busy doctor down the far end of the hall and they may decide to just pop in and see their patient for a second, instead of taking the long walk back to the cart. Others follow the lead of the physician and, eventually, there will be a real need for the protection and it won’t be worn. The outcome is an increase in cluster outbreaks.”

Regulatory Requirements

Some of what one of the experts called “the metastasis of signage” can be laid at the feet of the various organizations that regulate healthcare in the U.S. For example, many signs and their placement are required by regulators with, as one hospital risk management expert says, little or no understanding of the impact the mandates have on sign pollution.

“There are guidelines from The Joint Commission and others indicating when you have to put signs up, and often mandate both their content and placement,” says Elaine Ziemba, managing director of risk management at the Stanford Hospitals and Clinics in Palo Alto, Calif. “Environmental health and safety people will decide signage related to medical gasses and fire safety, and biomedical engineering will make decisions related to their equipment.”

Warning signs are added according to the perceived needs of the specific discipline involved. Risk managers are not routinely consulted about warning signs and notices put up around her hospital, Ziemba says. There also is little guidance in the literature about the effectiveness of multiple warning signs, especially when compared with the wide range of studies that assess alert fatigue in electronic medical record systems.

Although hardly restricted to the requirements of The Joint Commission or other agencies, complex and wordy signs add to the visual chaos and actually impair compliance. “Too many signs try to communicate too much information out of a fear that they may be leaving something important out,” Dr. Bogner says. “It is a lot easier to put everything in than to distill things down to get to the nugget you want to get across.”

David Yu, MD, FACP, medical director of hospitalist services at Decatur Memorial Hospital in Decatur, Ill., agrees. A member of Team Hospitalist, Dr. Yu’s mantra is “less is better.” Put the fewest words possible on the sign, then educate the staff on how to implement the information.

“We discourage signs that are overly verbose,” he says. “At the end of the day, the efficacy of signs depends largely on the training and attentiveness of those caring for the patient. It is not fail-safe and requires the staff to acknowledge the sign and institute the indicated policies correctly.”

In some cases, the best sign might not even be a sign.

“Color coding is used extensively in the military,” Dr. Yu says. “On an aircraft carrier, all of the people running around the deck are color-coded. Just by looking around, you can see who deals with armament, who is the refueler, and who does traffic control.”

Dr. Yu’s hospital issues red footies to patients who are at high risk for falls. When any staff member sees a red-footed patient wandering around without an escort, they immediately know they should intervene. It conveys the required message anywhere in the hospital.

I would like to see a system where only truly high-risk patients are the ones who get the warnings.

—David Grace, MD, FHM, area medical officer, Schumacher Group, Lafayette, La.

“Fire and Forget”

Although many visual warnings have the best of intentions, it doesn’t mean they are effective. Few hospitals have systems in place to follow up and make sure the warning actually has an effect on patient care.

“Alerts should be viewed initially as an experiment, requiring tracking to make sure it works as intended,” says Scott A. Flanders, MD, FHM, president of SHM and professor of medicine and director of the hospitalist program at the University of Michigan at Ann Arbor. “Too frequently in healthcare we put up signs in an attempt to fix a problem, but then don’t follow up to see if it is working.”

A similar phenomenon is seen when early warnings follow a patient through subsequent hospitalizations. This is especially true with isolation protocols, as the patient might not require the same warnings as previous admissions.

“It seems as though anyone who has ever had methicillin-resistant Staphylococcus aureus [MRSA] gets one of those things slapped on their door the minute they come in,” Dr. Grace says. “I have personally seen patients who had a boil grow out [of] MRSA 10 years ago still get a sticker on their door after all this time.”

Thus, warning signs that are not serving their intended purpose don’t ever get taken down; they dilute the usefulness of those that are timely and effective. The trend might indicate that defensive signage (a cousin to defensive medicine) is a driver, the theory being it’s safer and “legally defensible” if a hospital posts a multitude of alerts, rather than miss a sign that could have averted a poor outcome.

Clear and Consistent

Dr. Bogner, chief scientist at the Institute for the Study of Human Error, says the warning signs in your hospital should:

  • Convey a concise message;
  • Avoid vague terms and jargon;
  • Underscore the message with universally accepted symbols;
  • Present the message in a large, easy-to-view font surrounded by empty space;
  • Highlight the information in a redundant manner (e.g., “MSRA” always printed in red letters on a white background);
  • Be designed in consultation with those who will actually be using the warnings; and
  • Be placed as close to the action as possible (e.g., on the arm that is not eligible for blood draws).—KU

Effectiveness Questioned

Even though hospitalists have witnessed a marked increase in visual warnings, there is little to suggest they are effective. For example, studies in Asia during the 2003 SARS scare suggest that isolation precautions were followed closely, yet there was no change in MRSA transmission rates.

The other concern is whether the saturation of warnings causes harm. Dr. Grace receives a warning flag on almost every chart requesting DVT prophylaxis—even for patients who are on heparin infusions or already are on prophylaxis. “Doctors get frustrated and start to ignore the [alerts],” he says. “Then, when someone slips through the cracks and doesn’t get needed treatment, we are less likely to catch it because of alert fatigue.”

Although they are the most visual, and perhaps the most frustrating, part of patient safety, warning signs are not the only bullets in the gunfight.

“I don’t think any institution views [warning] signs as the ultimate solution to problems,” Dr. Flanders says. “Signs end up being one part of a multifactorial intervention—a common and easy first piece of the puzzle.”

Warning signs in the hospital can serve an important communication function, alerting providers of key safety concerns. However, too many warnings can dilute the effectiveness of the signage and hinder patient care.

Hospitalists need to recognize the possibility of sign fatigue in their own practice and link warnings to truly high-risk situations. Alerts can be of help, but they should be viewed as a back-up—not a substitute—for good communication between physicians, colleagues, and the hospital staff. TH

Kurt Ullman is a freelance writer based in Indiana.

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