Near-Fatal Med Incident Leads Hospital To Redesign Alerts

Posted on June 13, 2018 I Written By

Anne Zieger is veteran healthcare branding and communications expert with more than 25 years of industry experience. and her commentaries have appeared in dozens of international business publications, including Forbes, Business Week and Information Week. She has also worked extensively healthcare and health IT organizations, including several Fortune 500 companies. She can be reached at @ziegerhealth or www.ziegerhealthcare.com.

It only took a couple of mistakes – but they nearly led to tragedy.

Not long ago, a patient with a deadly allergy to a common pain reliever was admitted to Brockton, Mass.-based Good Samaritan Medical Center. The patient’s allergy was recorded in the EMR. But somehow, despite the warning generated by the system, a nurse practitioner ordered the medication and a pharmacist approved it. The patient recovered but was forced to spend time in the ICU, according to a story in the Boston Globe.

When state and federal regulators descended upon the hospital, its leaders said that they felt alert fatigue was a factor in the error. Of course, this forced the hospital to address some complex issues and the path wasn’t simple. CMS almost booted Good Samaritan from the Medicare program over the issue, in part because it didn’t address the problem quickly enough.

Since then, parent company Steward Health Care has made changes to the EMRs at all of the facilities to cut the chances of patients being harmed by alert fatigue.

Today, if a new patient at any of the Steward hospitals has a serious drug to allergy, they must follow a new procedure. Under new rules, a pharmacist cannot place an order for any of the potentially harmful drugs until they speak with the doctor or nurse to discuss alternative treatments.

Dr. Joseph Weinstein, chief medical officer at the health system, told the newspaper that the new procedure forces staff who are “moving through screens at a rapid pace” to stop. “The two people have to sign off on [the prescription] together,” he said. “This is one of the safest ways to reduce alert fatigue.”

Steward also cut back the list of reasons providers can override analogy alert from 14 to 7 of the most important, giving them a shorter list of items to read through and check off as part of the process.

It’s good to see that Steward was able to learn from the medication error and improve the alarm systems across its entire hospital network. These changes are likely to make a difference in day-to-day patient care and reduce the odds of patient harm.

That being said, clinicians are still besieged by alerts generated for other reasons, and simplifying one process, however vital, can only shave off points of the larger problem.

It seems to me that vendors ought to be more involved in the process of refining alerts rather than making individual hospitals figure out how to do this. Sure, hospitals need to address their individual circumstances but vendors need to take more responsibility the problem. There’s no getting away from this issue.