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How DeKalb Medical Fixed Drug Safety Problems After Fatal Error

By Steven Porter  
   April 26, 2018

Patient safety leaders slashed the number of overridden medication safety alerts by 60% in the first month of targeted interventions.

A nursing home patient with dementia who was admitted last October to DeKalb Medical in Decatur, Georgia, died after the hospital gave her 10 times the maximum daily dose of a calcium channel blocker.

The overdose death resulted in a finding of immediate jeopardy by the Centers for Medicare & Medicaid Services and spurred a series of patient safety reforms, many of which seek to reduce overreliance on technology.

"Our staff, physicians, pharmacists, nurses, other healthcare team members—and I don't think this is unique to our hospital system—have become very task-oriented in their actions as it relates to working with an electronic medical record," said Sharon Mawby, MSN, RN, NEA-BC, vice president of patient care services and chief nursing officer for DeKalb.

"Many hospitals, in an effort to decrease keystrokes for a practitioner, have developed order sets and systems which allow our practitioners to simply check boxes or choose from dropdown screens," she said.

That efficiency, without proper safeguards, can make it easier for healthcare workers to carry out unsafe orders methodically, without a second thought, Mawby said.

"Why aren't we asking questions?" she added. "Why aren't we stopping to listen to our gut when something doesn't feel right?"

What went wrong

The doctor who ordered 100 mg of amlodipine besylate tablets failed to second-guess an existing error made by another physician in the patient's file. A pharmacist tasked with reviewing the order missed the error as well, even though DeKalb's medication management system alerted the pharmacist to the unsafe dosage.

Pharmacists may mistakenly override a medication safety alert because they are inundated with false alarms, DeKalb's pharmacy director told inspectors after the fatal incident, according to an inspection report CMS released to HealthLeaders Media in response to a public records request.

The rate of adverse drug events originating during an inpatient stay at U.S. hospitals declined 23.8% from 2010 to 2014, falling most dramatically among patients ages 65 and older, according to a study released in January by the Agency for Healthcare Research and Quality Healthcare Cost and Utilization Project.

But the quality concerns over "alert fatigue," which can make it more difficult to catch medication errors before they harm patients, continue to plague hospitals and health systems nationwide.


Steven Porter is editor at HealthLeaders.

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