Massachusetts hospital tackles alert fatigue after staff overlooked patient's deadly allergy warning

Written by Megan Knowles | June 07, 2018 | Print  |

Hospital leaders at Brockton, Mass.-based Good Samaritan Medical Center are working to curb alert fatigue after a nurse administered a pain reliever to a patient whose EMR showed a life-threatening allergy to the drug last winter, The Boston Globe reports.

Here are six things to know:

1. The patient had a deadly allergy to a common type of pain reliever, which staff noted on the patient's EMR, according to a federal and state inspection report obtained by The Boston Globe. Neither the nurse practitioner who ordered the medication nor the pharmacist who approved it noticed the warning box for the patient's allergy on their computers. The patient experienced a severe allergic reaction and had to be transferred to the intensive care unit, where he later recovered, according to hospital leaders.

2. In the inspection report, hospital leaders said alert fatigue may have contributed to the medication error.

3. After the error, Joseph Weinstein, MD, CMO of Boston-based Steward Health Care, which operates Good Samaritan, said the company made changes to the EMR systems at each of its 10 Massachusetts hospitals to curb the risk of alert fatigue.

4. Under this system, if a patient has a serious drug allergy, the pharmacist cannot place the order until discussing alternative treatments with the provider who prescribed the drug. The process requires staff "moving through screens at a rapid pace" to stop, Dr. Weinstein said. "The two people have to sign off on it together. This is one of the safest ways to reduce alert fatigue."

5. Additionally, Steward cut the list of reasons providers can override an allergy alert from 14 to the seven most important, so caregivers do not have as many items to read through and check off.

6. CMS threatened to terminate Good Samaritan's Medicare program — partially because executives did not improve its alert system fast enough, the agency said in a letter to the 267-bed hospital. However, Good Samaritan avoided CMS discipline after inspectors returned to the hospital March 26 and found it was back in compliance with Medicare rules.

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