Case study: How DeKalb Medical cut its overridden medication safety alerts after fatal accident
Briefings on Accreditation and Quality, August 1, 2018
This is an excerpt from a member only article. To read the article in its entirety, please login or subscribe to Briefings on Accreditation and Quality.
One month after a fatal error, patient leaders were able to reduce overridden safety alerts by 60%
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 drop-down screens," she says.
This is an excerpt from a member only article. To read the article in its entirety, please login or subscribe to Briefings on Accreditation and Quality.
Related Products
Most Popular
- Articles
-
- Math can be tricky: TJC corrects ABHR storage requirement
- Air control equals infection control
- Don't forget the three checks in medication administration
- Note similarities and differences between HCPCS, CPT® codes
- Residency coordinators’ responsibilities
- The consequences of an incomplete medical record
- OB services: Coding inside and outside of the package
- Study: Shorter shifts reduces residents’ attentional failures
- Five ways to safeguard your patients' valuables
- Practice the six rights of medication administration
- E-mailed
-
- OSHA HazCom updates include labeling, SDS requirements
- Air control equals infection control
- Q&A: Are colleges sending students to our facility for rotations business associates?
- Patient classification systems to coordinate patient care
- Nursing's growing role
- Note similarities and differences between HCPCS, CPT® codes
- Note from the instructor: CMS clarifies billing guidelines on proper billing for drugs in a single-dose or single-use vial, including billing for discarded drugs
- Fracture coding in ICD-10-CM requires greater specificity
- Five ways to safeguard your patients' valuables
- Differentiate between types of wound debridement
- Searched