Time for Alert-ology or RE-sensitization?

In their case report in this issue of Pediatrics, Carspecken et al1 describe a child for whom the diagnosis of furosemide allergic hypersensitivity was delayed due to false-positive allergy alert overrides to other drugs. Although articles demonstrating the incidence and prevalence of alert fatigue are not new, I compliment Carspecken for the transparency as to how fatigue from falsepositive electronic medical record (EMR) alerts may have adversely affected patient care. I am sure that most of us can review the case report, as can the authors, and will be able to pick apart many case details and see where improvements in the process of care could have been made. As we critique the events as described in this report, I hope that we do so, however, in the spirit of curiosity and in the context of using this case report to foster a culture of safety.