CDSS Educational Poster Assignment

1. Problem Identification

Audience: All interprofessional providers (MDs, NPs, PAs, RNs, PharmDs) at this facility.

The Concern: Our facility’s goal is 100% compliance with Clinical Decision Support System (CDSS) alerts to ensure maximum patient safety. Recent performance data shows a significant gap:

• CDSS Compliance: 81.4% (18.6% below target)
• Provider Approval: 76%
• Primary Barriers: Cited reasons for non-compliance include mistrust of the system and a fear of potential diagnostic errors.

This data shows that while most providers approve of the CDSS, a significant number still bypass alerts, creating a safety risk. This poster will outline the benefits of the CDSS, the risks of bypassing it, and strategies to build trust and improve compliance.

2. Benefits of Using the CDSS

The CDSS is not a replacement for clinical judgment; it is a safety net designed to support it. Using the CDSS benefits you, your team, and your patients.

• Reduces Medication Errors: The CDSS flags potential drug-drug interactions, dose errors, and patient allergies. Studies show that CPOE with CDSS can reduce serious medication errors by 55% (Radley et al., 2013).
• Promotes Evidence-Based Practice (EBP): The system integrates the latest clinical guidelines at the point of care. This ensures all patients receive care based on the most current EBP, reducing practice variability and improving outcomes (Ricarte et al., 2022).
• Improves Efficiency and Outcomes: CDSS provides targeted reminders for preventative care (e.g., vaccinations, cancer screenings) and suggests appropriate diagnostic tests, reducing missed diagnoses and improving long-term health.

Supporting Evidence: A 2022 systematic review by Ricarte et al. found that CDSS implementation significantly improves adherence to clinical guidelines and reduces the risk of adverse events, acting as a “fundamental tool for incorporating EBP” into the workflow.

3. Risks of Bypassing CDSS Alerts

Bypassing alerts, even “nuisance” ones, is a high-risk behavior. Alert fatigue is real, but overriding warnings exposes you and your patient to preventable harm.

• Patient Harm: The most significant risk is a preventable adverse event. This includes prescribing a medication that has a critical interaction with another (e.g., serotonin syndrome) or missing a critical lab value alert (e.g., hyperkalemia).
• Diagnostic Errors: Ignoring alerts can lead to missed diagnoses. A systematic review found that CDSS improves diagnostic accuracy, and bypassing alerts is a “major source of medical error” (Sutton et al., 2020). This is the exact outcome providers fear, yet bypassing *increases* this risk.
• Legal and Professional Liability: In a malpractice lawsuit, a lawyer will review the EHR. If an adverse event occurred and the provider was found to have bypassed a relevant CDSS alert, it can be used as clear evidence of negligence, placing the provider’s license and the facility’s reputation at risk.

Supporting Evidence: Sutton et al. (2020) concluded that while CDSS is not perfect, “over-reliance on human vigilance” in complex data environments is a greater risk than using the system. Bypassing alerts removes the system’s “digital safety net” (Sutton et al., 2020).

4. Strategies to Increase CDSS Use & Trust

Our goal is to fix “alert fatigue,” not blame providers. We will use an interprofessional approach to build trust and improve the system.

• Workflow Integration Training: We will launch mandatory 1-hour training sessions (by role) focused *not* on what the CDSS is, but on *how* to use it efficiently within your specific workflow.
• Establish an “Alert Optimization” Committee: We will create an interprofessional team (MD, RN, PharmD, IT) to review the most frequently bypassed alerts. This team will have the power to customize, tier, or turn off low-priority alerts to reduce “noise” and increase the impact of critical warnings (Ricarte et al., 2022).
• Appoint and Train Unit “Super-Users”: We will identify clinical champions on each unit to act as “super-users.” These are your peers, not IT, who can provide immediate, 1-on-1 support and gather feedback on system mistrust to bring to the optimization committee.

Supporting Evidence: Ricarte et al. (2022) found that strategies “involving users in the design and implementation process” and “providing continuous training” were the most effective ways to overcome provider resistance and ensure long-term adoption.

5. Reflection for the Advanced Practice Nurse

As a future Advanced Practice Nurse (APN), this data is a call to leadership. My role will not be to simply *use* the CDSS, but to *lead* its implementation and improvement. The knowledge that mistrust is a key barrier will change my practice. Instead of just telling my team to “follow the alerts,” I will be a bridge between the clinical team and IT. I can use this tool by actively participating in the “Alert Optimization” committee, using my clinical judgment to help refine the alerts so they are meaningful, not burdensome. This shifts my role from a passive user to an active champion for patient safety, ensuring the technology serves the clinician, and not the other way around. This knowledge will improve my effectiveness by giving me a framework to address resistance, not with discipline, but with data-driven solutions and collaborative training.