Case study: Cutting overridden medication safety alerts at DeKalb Medical
Patient Safety Monitor, July 1, 2018
This is an excerpt from a member only article. To read the article in its entirety, please login or subscribe to Patient Safety Monitor.
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.
This is an excerpt from a member only article. To read the article in its entirety, please login or subscribe to Patient Safety Monitor.
Related Products
-
Patient Safety Monitor
Patient Safety Monitor is a searchable, web-based crosswalk that organizes state, CMS, and Joint Commission requirements by...
-
Patient Safety Monitor Insider
This e-mail newsletter provides healthcare professionals with the latest patient safety news, while offering useful...
-
Patient Safety Monitor - 1 Year Electronic
Patient Safety Monitor is a searchable, web-based crosswalk that organizes state, CMS, and Joint Commission requirements by...
-
Patient Safety Monitor - 1 Year Print and Electronic
Patient Safety Monitor is a searchable, web-based crosswalk that organizes state, CMS, and Joint Commission requirements by...
-
Patient Safety Monitor - 2 Year Electronic
Patient Safety Monitor is a searchable, web-based crosswalk that organizes state, CMS, and Joint Commission requirements by...
Most Popular
- Articles
-
- Practice the six rights of medication administration
- Don't forget the three checks in medication administration
- Note similarities and differences between HCPCS, CPT® codes
- Code diagnoses and outpatient treatment for PTSD
- What to include on the incident report
- Q&A: Primary, principal, and secondary diagnoses
- Skills of effective case managers
- Refine the terms: Understand unbilled accounts and DNFB
- OB services: Coding inside and outside of the package
- Differentiate between types of wound debridement
- E-mailed
-
- Skills of effective case managers
- Use discretion in the waiting room
- The pros and cons of geographic rounds
- Q&A: Determine medical necessity for inpatient admissions for COPD
- ICD-10-CM coma, stroke codes require more specific documentation
- Correctly bill ancillary bedside procedures in addition to the room rate
- Coding, billing, and documentation tips for teaching physicians, interns, residents, and students
- Coding isolation on the MDS 3.0
- Best practices for implementing new competencies
- Searched
