Case study: Cutting Overridden Medication Safety Alerts at DeKalb Medical

This member-only article appears in the July issue of Patient Safety Monitor Journal.

DeKalb Medical is a nonprofit health system based out of Decatur, Georgia, with 627 beds across its three campuses. The facility was the first in Georgia to receive an international “Baby-Friendly” hospital designation, an impressive feat as America’s maternal mortality rates shoot up. And 83 out of the 800 physicians working for DeKalb were named “Top Doctors” by Atlanta Magazine in 2017.

But, last October the hospital was placed under immediate jeopardy following the death of a patient with dementia. After being admitted from a nursing home, the patient was given 10 times the maximum daily dose of a calcium channel blocker, causing a fatal overdose.

DeKalb Medical officers self-reported the incident to CMS and released a statement saying they “want to make sure it never happens again.” The case has 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,” says 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 says.

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

“Why aren’t we asking questions?” she adds. “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.

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