See this month’s Great Catch winners and a medication safety update below.

Great Catches

• Thank you, Megan Rushe and Ian Muncy, from the Kettering Health Miamisburg Pharmacy. Orders were placed for potassium repletion for a patient. The patient’s potassium was in range and there was no apparent reason for the order. New orders for insulin were also entered. The provider placing the orders was a new resident. Megan and Ian had a Questioning Attitude and sent a MatchMD the resident, who realized the orders were placed on the wrong patient. The orders were discontinued and entered on the correct patient. Thank you, Megan and Ian, for Having a Questioning Attitude and keeping our patients safe.  

• Thank you, Nannette Maginnis, from the MRI Department at Kettering Health Main Campus. A patient was sent to receive an MRI with a “clear” MRI questionnaire. The patient answered “no” to all questions with the bedside RN. When the patient arrived for their MRI, Nannette went over the questionnaire again. The patient disclosed he formerly worked at a metal foundry and got metal in his eye once. The MRI Department sent the patient for an X-ray and discovered a small piece of metal still in his eye. Had this not been caught, the MRI could have damaged his eyesight. Thank you, Nannette, for Paying Attention to Detail and keeping our patients safe.

Medication safety: Medication administered too soon

We continually implement system enhancements including safe medication practices to provide the most appropriate care to our patients. We have noticed an increase in SAFE medication error reports for medications being administered too soon. An Epic best practice advisory (BPA) appears to warn that the medication is being administered too soon but the alert is ignored and bypassed at times. When medication is given too soon, the user is not following the provider’s order and this could lead to patient harm.

The Epic BPA was refined and redesigned to now include the following information

• Medication name, dose, and frequency
• Last administration time and date of the dose
• Acknowledgement reason is now a required action for the end user

This BPA is intended to prevent administering medications too soon and ensure the provider’s orders are being followed as prescribed.