Alert fatigue measurement in clinical decision support: a systematic review

Clinical Snapshot

Key Findings

• P Value: Not reported — narrative and descriptive synthesis only

• Effect Size: Not applicable — this is a methodological umbrella review with descriptive/narrative synthesis; no pooled effect size is reported or appropriate

• Primary Outcome: Only one of 22 included systematic reviews provided an operational definition of alert fatigue. The most commonly reported alert-related metrics were alert quantity, override rate, and acceptance rate. Studies reported between 1 and 11 distinct alert metrics. Reporting of primary study characteristics across included systematic reviews was frequently judged to be insufficient.

• Nnt Or Sensitivity: Not applicable — the review does not evaluate a therapeutic intervention or diagnostic test. The key metric is the proportion of included systematic reviews providing an operational definition of alert fatigue: 1/22 (4.5%)

• Confidence Interval: Not applicable — no quantitative pooling performed

Clinical Application

The review's primary contribution is methodological rather than immediately implementable. The proposed operational definition — a significant, sustained decrease in appropriate alert response rates from an established baseline — requires infrastructure for longitudinal alert response monitoring, which may not be available in all health systems. Implementation feasibility depends heavily on EHR capabilities, data extraction infrastructure, and institutional commitment to CDS governance. Alert fatigue is a recognised challenge in Australian healthcare settings, particularly within hospital EHR systems such as Epic, Cerner, and Meditech, which are increasingly deployed across public and private hospitals. The Australian Commission on Safety and Quality in Health Care (ACSQHC) has identified CDS as a key component of the National Safety and Quality Health Service (NSQHS) Standards, particularly Standard 4 (Medication Safety). The TGA does not directly regulate CDS alert content, but alert-related adverse events may be reportable under the Incident Information Management System (IIMS) in NSW and equivalent systems in other states. The RACGP has not issued specific guidance on alert fatigue measurement in general practice EHR systems (e.g., Best Practice, Medical Director), representing a gap in primary care informatics governance. The findings of this review are directly relevant to Australian health informatics professionals seeking to establish standardised metrics for CDS performance evaluation and alert optimisation programs. Healthcare organisations and clinical informatics teams implementing or evaluating physician-directed CDS alert systems in any acute or ambulatory care setting. Particularly relevant for hospital pharmacy, antimicrobial stewardship, medication safety, and clinical informatics departments seeking to measure or reduce alert fatigue.

Abstract

BACKGROUND: Alert fatigue is defined as alert dismissals due to excessive or irrelevant alerts and is frequently cited as a barrier to clinical decision support system use and impact. However, the criteria for determining the presence or absence of alert fatigue are poorly defined. The objective of this systematic review of systematic reviews was to identify operationalized definitions and measures of alert fatigue or alert-related metrics. METHODS: Systematic reviews reporting at least one alert-related metric or measure/operationalization of alert fatigue for physician-directed electronic alerts were included. The Cochrane Library, Embase, and PubMed were searched from database start to 2024. The Revised Assessment of Multiple Systematic Reviews was used to assess study quality and risk of bias. Data were synthesized narratively and with descriptive statistics. RESULTS: A total of 22 studies were included in the review. Studies reported between 1 and 11 alert metrics. Studies were most often of medium quality. Reporting of primary study characteristics was frequently judged to be insufficient. Only one article reported an operational definition of alert fatigue. The most common alert metrics were quantity, override rate, and acceptance rate. DISCUSSION: Alert fatigue measurement methods are not clearly or consistently defined in systematic reviews related to alert fatigue in clinical decision support. Reporting of other primary study characteristics is often limited. We recommend that future efforts use a significant, sustained decrease in appropriate alert response rates from an established baseline as a measure of alert fatigue.

References

1. 1.Ray, C. E., Wilson, G. M., Hughes, A. M., Cunningham Goedken, C., Liu, E. P.-F., Fitzpatrick, M. A., Suda, K. J., Kota, S. M., Nwankpa, C., & Evans, C. T. (2026). Alert fatigue measurement in clinical decision support: a systematic review. Journal of the American Medical Informatics Association: JAMIA. https://doi.org/10.1093/jamia/ocag064