One 40 kg (about 88 pounds) needed to

          One of the most common sentinel events that is discussed in
the 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 many
sentinel events are still caused by accidental overdosing. I was happy to be
able to find an article that not only talked about the issue of medication
overdose, but also, the effect of alarm fatigue and technological advancements
that had an effect on the specific medication overdose detailed below.


July 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 of
frequent infections and bowel inflammation. The patient became concerned the
night of his procedure, as he began to feel numb and his body was tingling all
over. While the patients nurse and supervising nurse could not find anything concerning
in regards to the medications given or the patients vitals, the chief resident
in pediatrics found an alarming discovery. It was discovered that the patient’s
nurse had mistakenly given the patient 38 ½ Septra pills, rather than one.
Unfortunately, when Poison Control was called, it was identified that an
overdose of this magnitude had never been reported which meant that the only course
of action was to monitor the patient closely. A few hours later, the patient
had a seizure and ended up passing away shortly after.


overdose of this routine anti-biotic at one of the nation’s leading hospitals
shows that this issue is still very much alive, despite the many efforts to
decrease these types of events from occurring. After looking further into the
issue, it was identified that a “mode error” within the recently implemented
Epic electronic medical record system had occurred. Some important things to
note, is that the hospital decided not to set any limits on the minimum doses
allowed for patients, since many patients that are seen are individuals with
rare diseases and many of them are on a treatment plan that includes what an
EMR system would consider as an “overdose”. Secondly, most pediatric
medications are based on weight, typically milligrams (mg) per kilogram (kg).
The hospital required that any patient under 40 kg (about 88 pounds) needed to
have weight-based dosing. Occasionally the requested dosage was not available,
so in order to ensure that the correct order is filled, if there was a
medication that was more than 5% off of the calculated “correct” dose, then the
pharmacist would need to receive another approval from the doctor for the new


patient from this case fell under the 88 pound threshold which meant that he
required a weight-based dosage. When the pediatric resident entered in the
request for Septra she chose the 5mg/kg option (double-strength) and the
computer multiplied it by his weight, which came out to 193 mg. Since a 193 mg
pill was not available, the system asked if providing a 160 mg Septra pill
would be sufficient, she approved. Because the calculated “correct dose” was
over the 5% threshold of what was actually ordered, the pharmacist processing
the order needed to change the order in the system to 160mg. While the
patient’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 be
redone in the correct number of mg. The pharmacist inquired the resident to
update the order with the recommended 160 mg, which when entered into the
system was written as 160 mg/kg due to an automation within Epic based off of
the patients weight. Because the units were mg/kg, the 160 was then multiplied
again by the weight of the patient, ultimately submitting an order for 6,160 mg
of Septra, or 38 ½ pills. One of the options that has come up to avoid system
errors like this, is to leave the units area blank which would require that
physicians or residents indicate units for every order. While this would help
to 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.


article also brought up an interesting idea surrounding alarm fatigue – the
idea that there are so many alarms that go off in a hospital setting, hospital
staff members often ignore or become immune to them, leaving room for errors
when important alarms are ignored. Specifically, in regards to this case, Epic
had certain alarm measures set-up internally, so that if any medications
conflicted, if a medication dosage was nearing a maximum or even if an overdose
of medication had been requested, the system would automatically alert the user
prior to submitting the order. While these alerts were helpful, they can also
become a nuisance when almost every other order has some sort of alert
associated with it, due to the warnings associated with various medications. It
was noted that because of this, it is common practice for some more senior
individuals to tell newer staff members to ignore the alerts, since usually
they can be safely ignored. However,
in this case, the overdose of Septra alarm warning was overlooked and caused a
fatal sentinel event. One item that the resident did mention about the alerts
is that alerts for overdoses look the same whether it is .1 mg over the
recommended dose or 100 mg over, which may have contributed to her overlooking
the alert in the first place. 

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