One of the most common sentinel events that is discussed inthe media is the accidental overdose of medication by hospital staff members,usually leading to patient fatalities.
When I looked into a quality paper, it was surprising to me how manysentinel events are still caused by accidental overdosing. I was happy to beable to find an article that not only talked about the issue of medicationoverdose, but also, the effect of alarm fatigue and technological advancementsthat had an effect on the specific medication overdose detailed below. InJuly of 2013 a teenage patient went into the hospital for a routine colonoscopy.He had a rare genetic disease – NEMO syndrome which leads to a lifetime offrequent infections and bowel inflammation. The patient became concerned thenight of his procedure, as he began to feel numb and his body was tingling allover. While the patients nurse and supervising nurse could not find anything concerningin regards to the medications given or the patients vitals, the chief residentin pediatrics found an alarming discovery.
It was discovered that the patient’snurse had mistakenly given the patient 38 ½ Septra pills, rather than one.Unfortunately, when Poison Control was called, it was identified that anoverdose of this magnitude had never been reported which meant that the only courseof action was to monitor the patient closely. A few hours later, the patienthad a seizure and ended up passing away shortly after. Theoverdose of this routine anti-biotic at one of the nation’s leading hospitalsshows that this issue is still very much alive, despite the many efforts todecrease these types of events from occurring. After looking further into theissue, it was identified that a “mode error” within the recently implementedEpic electronic medical record system had occurred.
Some important things tonote, is that the hospital decided not to set any limits on the minimum dosesallowed for patients, since many patients that are seen are individuals withrare diseases and many of them are on a treatment plan that includes what anEMR system would consider as an “overdose”. Secondly, most pediatricmedications are based on weight, typically milligrams (mg) per kilogram (kg).The hospital required that any patient under 40 kg (about 88 pounds) needed tohave weight-based dosing. Occasionally the requested dosage was not available,so in order to ensure that the correct order is filled, if there was amedication that was more than 5% off of the calculated “correct” dose, then thepharmacist would need to receive another approval from the doctor for the newconversion.
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Thepatient from this case fell under the 88 pound threshold which meant that herequired a weight-based dosage. When the pediatric resident entered in therequest for Septra she chose the 5mg/kg option (double-strength) and thecomputer multiplied it by his weight, which came out to 193 mg. Since a 193 mgpill was not available, the system asked if providing a 160 mg Septra pillwould be sufficient, she approved. Because the calculated “correct dose” wasover the 5% threshold of what was actually ordered, the pharmacist processingthe order needed to change the order in the system to 160mg. While thepatient’s weight required the resident to enter the order by weight-based measures(mg/kg), the 5% policy required the pharmacist to request that the order beredone in the correct number of mg. The pharmacist inquired the resident toupdate the order with the recommended 160 mg, which when entered into thesystem was written as 160 mg/kg due to an automation within Epic based off ofthe patients weight. Because the units were mg/kg, the 160 was then multipliedagain by the weight of the patient, ultimately submitting an order for 6,160 mgof Septra, or 38 ½ pills.
One of the options that has come up to avoid systemerrors like this, is to leave the units area blank which would require thatphysicians or residents indicate units for every order. While this would helpto make the individual stop to think about the order that they are requesting,it has been noted that it also requires a large number of additional “clicks”when using the EMR. Thearticle also brought up an interesting idea surrounding alarm fatigue – theidea that there are so many alarms that go off in a hospital setting, hospitalstaff members often ignore or become immune to them, leaving room for errorswhen important alarms are ignored. Specifically, in regards to this case, Epichad certain alarm measures set-up internally, so that if any medicationsconflicted, if a medication dosage was nearing a maximum or even if an overdoseof medication had been requested, the system would automatically alert the userprior to submitting the order. While these alerts were helpful, they can alsobecome a nuisance when almost every other order has some sort of alertassociated with it, due to the warnings associated with various medications. Itwas noted that because of this, it is common practice for some more seniorindividuals to tell newer staff members to ignore the alerts, since usuallythey can be safely ignored.
However,in this case, the overdose of Septra alarm warning was overlooked and caused afatal sentinel event. One item that the resident did mention about the alertsis that alerts for overdoses look the same whether it is .1 mg over therecommended dose or 100 mg over, which may have contributed to her overlookingthe alert in the first place.
