Introduction

High Reliability Organizations (HROs) such as aviation and healthcare operate in environments where precision is indispensable and errors can have severe repercussions. Aviation, with its rigorous safety protocols and state-of-the-art technological systems, is often regarded as a benchmark HRO. This article explores a specific aviation incident to elucidate the delicate interplay between alert sensitivity and alert fatigue in healthcare, leading to the insightful realization that, in the realm of Clinical Decision Support (CDS) alerts, less can indeed be more.

Background

On March 7, 2020, a serious incursion occurred at Toronto's Lester B. Pearson International Airport involving an Embraer 190-100 and a Boeing 777-300, both operated by Air Canada. This event represented a significant incursion that necessitated thorough investigation. An incursion in aviation refers to any occurrence involving the incorrect presence of an aircraft, vehicle, or person on the protected area of a surface designated for the landing and take-off of aircraft.

In this incident, the Embraer, while initiating its takeoff, collided with a bird and subsequently initiated a rejected takeoff. Simultaneously, the Boeing 777, unaware of the Embraer’s situation due to overlapping radio transmissions, was instructed to commence their take-off roll. Observing the stationary Embraer 190 on the runway, the Boeing 777 also initiated a rejected takeoff. Both aircraft, came within approximately 3800 feet of each other on the runway. Fortunately, in the end, no injuries or damage occurred.

Critical to this incident were the advanced surface movement guidance and control systems (A‑SMGCSs) and the runway incursion monitoring and conflict alert system (RIMCAS), which failed to sound an alarm due to their reliance on the aircraft’s transponder transmission as the primary indication of airborne status. The full report by Director General, Civil Aviation Transport Canada can be found here.

Analysis and Reflection

This incident highlights the crucial, yet imperfect, role of alert systems in averting accidents. The systems were configured with a threshold that, in this instance, resulted in missed alerts. A seemingly logical solution might be to lower the threshold for alarms to encompass all potential incidents, a tactic mirrored in many global hospitals using electronic health records.

However, investigators wisely discerned that indiscriminately lowering the threshold could lead to "alert fatigue," thereby undermining safety. This phenomenon is prevalent in healthcare, where a surplus of CDS alerts leads to desensitization and habitual dismissal of such alerts by physicians. The paradox is that the proliferation of alerts can paradoxically reduce responsiveness to critical alerts due to the overwhelming volume of notifications, compromising both aviation and patient safety.

The report states, "it may also inadvertently cause false alarms in other situations. This could, in turn, reduce controllers’ confidence in the sub-system." This loss of confidence is not unique to aviation; it has pervaded the medical field as well. Physicians everywhere have already lost confidence in the CDS system due to the overwhelming and often irrelevant alerts, which have become more of a hindrance than a help in many cases./p>

Contrast with Healthcare

In healthcare, the rampant implementation of alert systems, often without comprehensive analysis, results in an overload of alerts and subsequent alert fatigue among healthcare providers. The failure of the A‑SMGCSs and RIMCAS in the aviation incident serves as a stark reminder that more alerts do not necessarily translate to increased safety. In fact, the indiscriminate addition of alerts can be detrimental, reducing the likelihood of response to genuinely critical alerts due to alert saturation.

Conclusion

Achieving a balance between alert sensitivity and alert fatigue is a nuanced endeavor that necessitates meticulous analysis and judicious implementation. The aviation and healthcare sectors can mutually benefit by learning from each other in formulating effective alert systems that augment safety without compromising alert responsiveness. It is imperative to optimize the use of safety alerts as a finite resource, ensuring maximal attention and response to each alert, to cultivate a safer and more reliable operational environment in high-risk industries.

This article serves as a beacon, illuminating the paradoxical truth that in the realm of CDS alerts in HROs, less is indeed more. The pursuit of high reliability and optimal safety in both aviation and healthcare beckons a deeper exploration and mutual learning, guiding the evolution of more refined and responsive safety protocols in environments where the stakes are exceptionally high.