It Takes Two to Make It Right: How Nurses’ Response to Sepsis Alerts Impacts Physicians’ Process Compliance

References

• Adjerid I, Ayvaci MUS, Özer Ö (2023) Value of algorithm-enabled process innovation: The case of sepsis. Manufacturing Service Oper. Management 25(4):1545–1566.Link, Google Scholar
• Agrawal A, Mayo-Smith MF (2004) Adherence to computerized clinical reminders in a large healthcare delivery network. Stud. Health Tech. Inform. 107(Pt 1):111–114.Google Scholar
• Anderson D, Gao GG, Golden B (2014) Life is all about timing: An examination of differences in treatment quality for trauma patients based on hospital arrival time. Production Oper. Management 23(12):2178–2190.Crossref, Google Scholar
• Anderson D, Golden B, Jank W, Wasil E (2012) The impact of hospital utilization on patient readmission rate. Healthcare Management Sci. 15(1):29–36.Crossref, Google Scholar
• Anderson D, Price C, Golden B, Jank W, Wasil E (2011) Examining the discharge practices of surgeons at a large medical center. Healthcare Management Sci. 14(4):338–347.Crossref, Google Scholar
• Andritsos DA, Tang CS (2014) Linking process quality and resource usage: An empirical analysis. Production Oper. Management 23(12):2163–2177.Crossref, Google Scholar
• Angrist J, Kolesár M (2024) One instrument to rule them all: The bias and coverage of just-ID IV. J. Econom. 240(2):105398.Crossref, Google Scholar
• Association of Clinical Documentation Improvement Specialists (2022) Demystifying and communicating case-mix index. Accessed November 1, 2024, https://acdis.org/sites/acdis/files/resources/CR-6483_ACDIS-Advisory%20Board%20CMI-WP_Final.pdf.Google Scholar
• Ayers AA (2017) Cost-effective staffing with medical assistants. J. Urgent Care Medicine 11(4):25–30.Google Scholar
• Ayvaci MUS, Mobini Z, Özer O (2023) To catch a killer: A data-driven personalized and compliance-aware sepsis alert system. Preprint, submitted April 6, https://doi.org/10.2139/ssrn.3805931.Google Scholar
• Batt RJ, Terwiesch C (2017) Early task initiation and other load-adaptive mechanisms in the emergency department. Management Sci. 63(11):3531–3551.Link, Google Scholar
• Benanav A (2020) Automation and the Future of Work (Verso Books, London).Google Scholar
• Bennett K (2016) The sepsis core measure. Accessed May 13, 2025, https://medicine-matters.blogs.hopkinsmedicine.org/2016/03/the-sepsis-core-measure/.Google Scholar
• Berry Jaeker JA, Tucker AL (2017) Past the point of speeding up: The negative effects of workload saturation on efficiency and patient severity. Management Sci. 63(4):1042–1062.Link, Google Scholar
• Bitan Y, Meyer J, Shinar D, Zmora E (2004) Nurses’ reactions to alarms in a neonatal intensive care unit. Cognition Tech. Work 6(4):239–246.Crossref, Google Scholar
• Bliss JP, Gilson RD, Deaton JE (1995) Human probability matching behaviour in response to alarms of varying reliability. Ergonomics 38(11):2300–2312.Crossref, Google Scholar
• Boev C, Xia Y (2015) Nurse-physician collaboration and hospital-acquired infections in critical care. Critical Care Nurse 35(2):66–72.Crossref, Google Scholar
• Bonafide CP, Lin R, Zander M, Graham CS, Paine CW, Rock W, Rich A, et al. (2015) Association between exposure to nonactionable physiologic monitor alarms and response time in a children’s hospital. J. Hospital Medicine 10(6):345–351.Crossref, Google Scholar
• Breznitz S (1984) Cry Wolf: The Psychology of False Alarms (Lawrence Erlbaum Associates, Hillsdale, NJ).Google Scholar
• Caro F, de Tejada Cuenca AS (2023) Believing in analytics: Managers’ adherence to price recommendations from a DSS. Manufacturing Service Oper. Management 25(2):524–542.Link, Google Scholar
• Celik U, Rath S, Kesavan S, Staats BR (2024) Frontiers in operations: Does physician’s choice of when to perform EHR tasks influence total EHR workload? Manufacturing Service Oper. Management 26(4):1190–1210.Link, Google Scholar
• Charron S, Koechlin E (2010) Divided representation of concurrent goals in the human frontal lobes. Science 328(5976):360–363.Crossref, Google Scholar
• Chassin MR, Galvin RW; National Roundtable on Health Care Quality (1998) The urgent need to improve health care quality: Institute of Medicine National Roundtable on Health Care Quality. JAMA 280(11):1000–1005.Crossref, Google Scholar
• Chassin MR, Loeb JM, Schmaltz SP, Wachter RM (2010) Accountability measures—Using measurement to promote quality improvement. New England J. Medicine 363(7):683–688.Crossref, Google Scholar
• Clarke-Myers K, Cooper DS, Hanke SP, Storey J, McDonald M, Kimball TR, Anderson JB (2019) Development of a system to measure and improve outcomes in congenital heart disease. Joint Commission J. Quality Patient Safety 45(7):495–501.Crossref, Google Scholar
• CMS (2025) Care Compare—Medicare. Hosted by the U.S. Department of Health and Human Services, “Care Compare” provides information about hospitals’ quality performance across the country. Accessed May 13, 2025, https://www.medicare.gov/care-compare/.Google Scholar
• Cook RI, Woods DD (1994) Operating at the sharp end: The complexity of human error. Bogner MS, ed. Human Error in Medicine (Lawrence Erlbaum Associates, Hillsdale, NJ), 255–310.Google Scholar
• Corbett CJ, Montes-Sancho MJ, Kirsch DA (2005) The financial impact of ISO 9000 certification in the United States: An empirical analysis. Management Sci. 51(7):1046–1059.Link, Google Scholar
• Dellinger RP, Levy MM, Rhodes A, Annane D, Gerlach H, Opal SM, Sevransky JE, et al. (2013) Surviving sepsis campaign: International guidelines for management of severe sepsis and septic shock: 2012. Critical Care Medicine 41(2):580–637.Crossref, Google Scholar
• Dietvorst BJ, Simmons JP, Massey C (2015) Algorithm aversion: People erroneously avoid algorithms after seeing them err. J. Experiment. Psych. General 144(1):114–126.Crossref, Google Scholar
• Elixhauser A, Steiner C, Harris DR, Coffey RM (1998) Comorbidity measures for use with administrative data. Medical Care 36(1):8–27.Crossref, Google Scholar
• Ergezen FD, Kol E (2020) Nurses’ responses to monitor alarms in an intensive care unit: An observational study. Intensive Critical Care Nursing 59:102845.Crossref, Google Scholar
• Fleming NS, Ogola G, Ballard DJ (2009) Implementing a standardized order set for community-acquired pneumonia: Impact on mortality and cost. Joint Commission J. Quality Patient Safety 35(8):414–421.Crossref, Google Scholar
• Freeman M, Savva N, Scholtes S (2017) Gatekeepers at work: An empirical analysis of a maternity unit. Management Sci. 63(10):3147–3167.Link, Google Scholar
• Gaieski DF, Edwards JM, Kallan MJ, Carr BG (2013) Benchmarking the incidence and mortality of severe sepsis in the United States. Critical Care Medicine 41(5):1167–1174.Crossref, Google Scholar
• Getty DJ, Swets JA, Pickett RM, Gonthier D (1995) System operator response to warnings of danger: A laboratory investigation of the effects of the predictive value of a warning on human response time. J. Experiment. Psych. Appl. 1(1):19–33.Crossref, Google Scholar
• Greene W (2018) Econometric Analysis, 8th ed. (Pearson, New York).Google Scholar
• Hallowell E (2005) Overloaded circuits: Why smart people underperform. Harvard Bus. Rev. 83(1):54–62.Google Scholar
• Herasevich V, Tsapenko M, Kojicic M, Ahmed A, Kashyap R, Venkata C, Shahjehan K, et al. (2011) Limiting ventilator-induced lung injury through individual electronic medical record surveillance. Critical Care Medicine 39(1):34–39.Crossref, Google Scholar
• Hertwig R, Barron G, Weber EU, Erev I (2006) The role of information sampling in risky choice. Fiedler K, Juslin P, eds. Information Sampling and Adaptive Cognition (Cambridge University Press, Cambridge, UK), 72–91.Google Scholar
• House S, Havens D (2017) Nurses’ and physicians’ perceptions of nurse-physician collaboration: A systematic review. J. Nursing Admin. 47(3):165–171.Crossref, Google Scholar
• Ibanez MR, Clark JR, Huckman RS, Staats BR (2018a) Discretionary task ordering: Queue management in radiological services. Management Sci. 64(9):4389–4407.Link, Google Scholar
• Ibanez B, James S, Agewall S, Antunes MJ, Bucciarelli-Ducci C, Bueno H, Caforio ALP, et al. (2018b) 2017 ESC guidelines for the management of acute myocardial infarction in patients presenting with ST-segment elevation. Eur. Heart J. 39(2):119–177.Crossref, Google Scholar
• Institute of Medicine (1999) To err is human: Building a safer health system. Technical report, National Academies Press, Washington, DC.Google Scholar
• Institute of Medicine (2001) Crossing the quality chasm: A new health system for the 21st century. Technical report, National Academies Press, Washington, DC.Google Scholar
• Institute of Medicine (2011) The future of nursing: Leading change, advancing health. Technical report, National Academies Press, Washington, DC.Google Scholar
• Kajaria-Montag H, Freeman M, Scholtes S (2024) Continuity of care increases physician productivity in primary care. Management Sci. 70(11):7943–7960.Link, Google Scholar
• Kaukonen K-M, Bailey M, Pilcher D, Cooper DJ, Bellomo R (2015) Systemic inflammatory response syndrome criteria in defining severe sepsis. New England J. Medicine 372(17):1629–1638.Crossref, Google Scholar
• KC DS (2014) Does multitasking improve performance? Evidence from the emergency department. Manufacturing Service Oper. Management 16(2):168–183.Link, Google Scholar
• KC DS (2020) Worker productivity in operations management. Foundations Trends Tech. Inform. Oper. Management 13(3):151–249.Crossref, Google Scholar
• Kesavan S, Kushwaha T (2020) Field experiment on the profit implications of merchants’ discretionary power to override data-driven decision-making tools. Management Sci. 66(11):5182–5190.Link, Google Scholar
• Kim S-H, Chan CW, Olivares M, Escobar G (2015) ICU admission control: An empirical study of capacity allocation and its implication for patient outcomes. Management Sci. 61(1):19–38.Link, Google Scholar
• Kuntz L, Mennicken R, Scholtes S (2015) Stress on the ward: Evidence of safety tipping points in hospitals. Management Sci. 61(4):754–771.Link, Google Scholar
• Lal A, Lockhart M, Xu Y, Zu Z (2024) How much should we trust instrumental variable estimates in political science? Practical advice based on 67 replicated studies. Political Anal. 32(4):521–540.Crossref, Google Scholar
• Lee JD, Moray N (1994) Trust, self-confidence, and operators’ adaptation to automation. Internat. J. Human-Comput. Stud. 40(1):153–184.Crossref, Google Scholar
• Levine DI, Toffel MW (2010) Quality management and job quality: How the ISO 9001 standard for quality management systems affects employees and employers. Management Sci. 56(6):978–996.Link, Google Scholar
• Levy MM, Rhodes A, Phillips GS, Townsend SR, Schorr CA, Beale R, Osborn T, et al. (2015) Surviving sepsis campaign: Association between performance metrics and outcomes in a 7.5-year study. Critical Care Medicine 43(1):3–12.Crossref, Google Scholar
• Lin W, Kim S-H, Tong J (2021) Revisiting the cause of algorithm aversion: Algorithm feedback asymmetry in the field and lab. Preprint, submitted August 25, https://doi.org/10.2139/ssrn.3891832.Google Scholar
• Ma C, Shang J, Bott MJ (2015) Linking unit collaboration and nursing leadership to nurse outcomes and quality of care. J. Nursing Admin. 45(9):435–442.Crossref, Google Scholar
• Makam AN, Nguyen OK, Auerbach AD (2015) Diagnostic accuracy and effectiveness of automated electronic sepsis alert systems: A systematic review. J. Hospital Medicine 10(6):396–402.Crossref, Google Scholar
• Maltz M, Meyer J (2001) Use of warnings in an attentionally demanding detection task. Human Factors 43(2):217–226.Crossref, Google Scholar
• Meyer J (2004) Conceptual issues in the study of dynamic hazard warnings. Human Factors 46(2):196–204.Crossref, Google Scholar
• Michtalik HJ, Yeh H-C, Pronovost PJ, Brotman DJ (2013) Impact of attending physician workload on patient care: A survey of hospitalists. JAMA Internal Medicine 173(5):375–377.Crossref, Google Scholar
• Miller AR, Tucker C (2018) Privacy protection, personalized medicine, and genetic testing. Management Sci. 64(10):4648–4668.Link, Google Scholar
• Muir BM, Moray N (1996) Trust in automation. Part II. Experimental studies of trust and human intervention in a process control simulation. Ergonomics 39(3):429–460.Crossref, Google Scholar
• Niewoehner RJ, Diwas K, Staats B (2023) Physician discretion and patient pick-up: How familiarity encourages multitasking in the emergency department. Oper. Res. 71(3):958–978.Link, Google Scholar
• Oliva R, Sterman JD (2001) Cutting corners and working overtime: Quality erosion in the service industry. Management Sci. 47(7):894–914.Link, Google Scholar
• Overhage JM, Tierney WM, McDonald CJ (1996) Computer reminders to implement preventive care guidelines for hospitalized patients. JAMA Internal Medicine 156(14):1551–1556.Google Scholar
• Parasuraman R, Davies D, eds. (1984) Varieties of Attention (Academic Press, London).Google Scholar
• Patterson ES, Doebbeling BN, Fung CH, Militello L, Anders S, Asch SM (2005) Identifying barriers to the effective use of clinical reminders: Bootstrapping multiple methods. J. Biomedical Inform. 38(3):189–199.Crossref, Google Scholar
• Pearl J (2001) Direct and indirect effects. Breese J, Koller D, eds. Proc. 17th Conf. Uncertainty Artificial Intelligence (Morgan Kaufmann Publishers, San Francisco), 411–420.Google Scholar
• Pearl J (2014) Interpretation and identification of causal mediation. Psych. Methods 19(4):459–481.Crossref, Google Scholar
• Peterson J, Bates DW (2001) Preventable medication errors: Identifying and eliminating serious drug interactions. J. Amer. Pharmaceutical Assoc. 41(2):159–160.Google Scholar
• Phillips J, Malliaris AP, Bakerjian D (2021) Nursing and patient safety. AHRQ Primers, Agency for Healthcare Research and Quality, Rockville, MD.Google Scholar
• Rangel-Frausto MS, Pittet D, Costigan M, Hwang T, Davis C, Wenzel R (1995) The natural history of the systemic inflammatory response syndrome (SIRS): A prospective study. JAMA 273(2):117–123.Crossref, Google Scholar
• Reinhart K, Daniels R, Kissoon N, Machado FR, Schachter RD, Finfer S (2017) Recognizing sepsis as a global health priority—A WHO resolution. New England J. Medicine 377(5):414–417.Crossref, Google Scholar
• Rhee C, Dantes R, Epstein L, Murphy DJ, Seymour CW, Iwashyna TJ, Kadri SS, et al. (2017) Incidence and trends of sepsis in US hospitals using clinical vs claims data, 2009-2014. JAMA 318(13):1241–1249.Crossref, Google Scholar
• Rosen MA, DiazGranados D, Dietz AS, Benishek LE, Thompson D, Pronovost PJ, Weaver SJ (2018) Teamwork in healthcare: Key discoveries enabling safer, high-quality care. Amer. Psych. 73(4):433–450.Crossref, Google Scholar
• Rudd KE, Johnson SC, Agesa KM, Shackelford KA, Tsoi D, Kievlan DR, Colombara DV, et al. (2020) Global, regional, and national sepsis incidence and mortality, 1990–2017: Analysis for the global burden of disease study. Lancet 395(10219):200–211.Crossref, Google Scholar
• Saleem JJ, Patterson ES, Militello L, Render ML, Orshansky G, Asch SM (2005) Exploring barriers and facilitators to the use of computerized clinical reminders. J. Amer. Medical Inform. Assoc. 12(4):438–447.Crossref, Google Scholar
• Saleem JJ, Patterson ES, Militello L, Anders S, Falciglia M, Wissman JA, Roth EM, Asch SM (2007) Impact of clinical reminder redesign on learnability, efficiency, usability, and workload for ambulatory clinic nurses. J. Amer. Medical Inform. Assoc. 14(5):632–640.Crossref, Google Scholar
• Seago J (2008) Professional communication. Seago JA, Hughes RG, eds. Patient Safety and Quality: An Evidence-Based Handbook for Nurses (Agency for Healthcare Research and Quality, Rockville, MD), 1–23.Google Scholar
• Sendelbach S, Funk M (2013) Alarm fatigue: A patient safety concern. AACN Adv. Critical Care 24(4):378–388.Crossref, Google Scholar
• Senot C, Chandrasekaran A, Ward PT, Tucker AL, Moffatt-Bruce SD (2016) The impact of combining conformance and experiential quality on hospitals’ readmissions and cost performance. Management Sci. 62(3):829–848.Link, Google Scholar
• Sequist TD, Gandhi TK, Karson AS, Fiskio JM, Bugbee D, Sperling M, Cook EF, Orav EJ, Fairchild DG, Bates DW (2005) A randomized trial of electronic clinical reminders to improve quality of care for diabetes and coronary artery disease. J. Amer. Medical Inform. Assoc. 12(4):431–437.Crossref, Google Scholar
• Shekelle PG (2013) Nurse-patient ratios as a patient safety strategy: A systematic review. Ann. Internal Medicine 158(5 Pt 2):404–409.Crossref, Google Scholar
• Singer M, Deutschman CS, Seymour CW, Shankar-Hari M, Annane D, Bauer M, Bellomo R, et al. (2016) The third international consensus definitions for sepsis and septic shock (Sepsis-3). JAMA 315(8):801–810.Crossref, Google Scholar
• Smith MW, Brown C, Virani SS, Weir CR, Petersen LA, Kelly N, Akeroyd J, Garvin JH (2018) Incorporating guideline adherence and practice implementation issues into the design of decision support for beta-blocker titration for heart failure. Appl. Clinical Inform. 9(2):478–489.Crossref, Google Scholar
• Sorkin RD (1988) Why are people turning off our alarms? J. Acoustical Soc. Amer. 84(3):1107–1108.Crossref, Google Scholar
• Staats BR, Dai H, Hofmann D, Milkman KL (2017) Motivating process compliance through individual electronic monitoring: An empirical examination of hand hygiene in healthcare. Management Sci. 63(5):1563–1585.Link, Google Scholar
• Sun J, Zhang DJ, Hu H, Mieghem JAV (2022) Predicting human discretion to adjust algorithmic prescription: A large-scale field experiment in warehouse operations. Management Sci. 68(2):846–865.Link, Google Scholar
• Tan TF, Netessine S (2014) When does the devil make work? An empirical study of the impact of workload on worker productivity. Management Sci. 60(6):1574–1593.Link, Google Scholar
• Tan T-C, Zhou H, Kelly M (2017) Nurse-physician communication—An integrated review. J. Clinical Nursing 26(23–24):3974–3989.Crossref, Google Scholar
• Uncapher MR, Thieu MK, Wagner AD (2016) Media multitasking and memory: Differences in working memory and long-term memory. Psychonomic Bull. Rev. 23(2):483–490.Crossref, Google Scholar
• Van Kippersluis H, Rietveld CA (2018) Beyond plausibly exogenous. Econom. J. 21(3):316–331.Crossref, Google Scholar
• Winters BD, Slota JM, Bilimoria KY (2021) Safety culture as a patient safety practice for alarm fatigue. JAMA 326(12):1207–1208.Crossref, Google Scholar
• Wooldridge JM (2002) Econometric Analysis of Cross Section and Panel Data (MIT Press, Cambridge).Google Scholar
• Wooldridge JM (2015) Control function methods in applied econometrics. J. Human Resources 50(2):420–445.Crossref, Google Scholar
• Wowak KD, Ball GP, Post C, Ketchen DJ (2021) The influence of female directors on product recall decisions. Manufacturing Service Oper. Management 23(4):895–913.Link, Google Scholar