HospitalInspections.org

Based on interviews and documentation review, it was determined that all corrective actions related to issues identified during the Hospital Investigation/Root Cause Analysis had not yet been implemented.

Findings include:

1.) The Hospital Internal Investigation/Root Cause Analysis identified that one of the causes of the adverse drug event was caused by the numerous alerts seen by pharmacists and physicians as they enter and verify orders (known as alert fatigue).

2.) The Chief Quality Officer was interviewed intermittently on 3/11/10 and 3/15/10. The Chief Quality Officer said a step taken was to remove ketoconazole for the Hospital's formulary. The Chief Quality Officer said discussions have occurred with the Chief Medical Information Officer to improve alert the functionality in the computer physician order entry system. The Chief Quality Officer said the project will require numerousness healthcare professionals and an extended amount of time to reconfigure this complex task.

3.) The Hospital's corrective actions indicated that a fundamental redesign of the alerting system will be undertaken and include a review of its medication alerting systems in the pharmacy and the electronic medical record in order to reduce alert fatigue for physicians and pharmacists. When the redesign is activated an extensive educational campaign will be undertaken.