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Case study: How DeKalb Medical cut its overridden medication safety alerts after fatal accident

Briefings on Accreditation and Quality, August 1, 2018

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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.

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