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and the Failing of SMART Healthcare
If you have yet to hear about this story, read along and try your level best to answer the questions
(answers at the end). Promise not to jump ahead to THE BIG REVEAL!

Pablo Garcia, a 16-year old patient, had a rare genetic disease known as NEMO
syndrome. As a result, he will always have to deal with infections and bowel
One morning in July 2013 at the University of California, San Francisco Medical
Center (UCSF), he complained of numbness and tingling, then went into
convulsions and stopped breathing.

The night before, Pablo took all Which medication do you think is the most
his evening medications which likely cause of Pablo’s adverse reaction?

included steroids, bowel-
cleansing solution, anti-nausea a) Steroids c) Anti-nausea
and anti-biotic pills. b) Bowel-cleansing d) Antibiotics

UCSF decided not to set limits on doses, reasoning that it is a teaching hospital
with lots of patients with rare diseases (many of them on research protocols) where
such “overdoses” would usually be fine.

For paediatrics, the Epic implementation committee decided to require weight-

based dosing for all children under 40 kilograms (about 88 pounds). Weight-
based doses may also need to be translated into number of pills.

What happens when a dose should be 120 mg (based on the child’s weight)
but the only available pill was 100 mg? The policy is for the pharmacist to contact
the physician to be sure the latter has endorsed that conversion, if the available
medication was more than 5% off the calculated “correct” dose.

When Jenny Lucca, a pediatrics resident at Pablo’s weight is

UCSF, was prescribing the antiobiotic Septra 38.6 kg. Multiplied
for Pablo Garcia, she was prompted to by 5 mg, his Septra
choose between two dose choices, and she dosage should be
chose the larger (“double-strength”) one, 193 mg. Septra 193mg
which contains 5 mg/kg of trimethoprim, one
1 2
of the two active ingredients in Septra.

There is no 193 What do you think the computer would

mg Septra pill; the recommend?
nearest tablet size is
the 160 mg double-
strength Septra pill. 2 a) Round down the dose
to a single tablet, well
above the 5% threshold)
b) Round down the
dose to 160 mg, far
from the 5% threshold

May 2016 Page 1

HIMSS Asia Pacific Exclusive Article

Lucca, the physician,

clicked “Yes” to the Do you agree with Lucca?
computer’s prompt and
Yes thought that she had
ordered the one double-
strength tablet.
3 a) Yes b) No

Chan instantly noticed a problem with

Benjamin Chan, as the pediatric this Septra order: the dose of 193 mg
clinical pharmacist, had to sign off the computer had calculated (based on
on all medication orders on the the teenager’s weight of 38.6 kg) was
pediatric service. 17% above the standard 160-mg Septra
double-strength tablets.

If you are Chan, what would you do?


4 a) Trust Lucca’s
judgement and
process the order
b) Contact Lucca to ask her to
enter the dose corresponding
to the actual pill size: 160 mg

This is the digital order form.

What do you think Lucca should type into

the empty field?

5 a) 5
b) 38.6
c) 160
d) None of the above

Is the dosage correct? Is Pablo’s Code Blue condition due to the Septra pills?
Read the Big Reveal to find out!

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HIMSS Asia Pacific Exclusive Article

The Big Reveal:

Well, Lucca typed “160” for the field “mg/kg of trimethoprim.

Unlike Lucca, can you spot the mistake? So Chan accepted Lucca’s order for 160 mg/kg.

After Lucca signed the order, an alert warned her of an Next, did the attending nurse suspect the dosage to
overdose. Lucca assumed that the alert she received be wrong?
after signing the Septra order was yet another annoying
one with no clinical significance, and so she clicked out
“I know that a doctor writes the prescription,” Levitt
of it. (In paediatrics, alerts fired on several of the 10 to
said. “The pharmacist always checks it... then it
15 medications ordered by the doctors and on the vast
comes to me ... I trusted the other two checks.”
majority of orders processed by the pediatric pharmacists
because of weight-based dosages.)
However, she refrained from calling the doctors or
nurses as they were busy and she did not want to
Lucca was asked how she could have clicked out of the
appear stupid. So, she asked her young patient
Septra overdose alert, knowing now that by doing so,
instead what he thought of the 38½ Septra pills.
she had confirmed an order for 38½ Septra tablets. She
blamed part of it on alert fatigue. But she also pointed to
the appearance of the alerts in Epic, saying that going 0.1 Pablo was used to taking unusual medications, so
milligram over a recommended dose  and this very large he said that the dose looked okay. She handed the
overdose all look exactly the same. pills to him and about six hours later, Pablo stopped
The Epic alert that Lucca received is later admitted to be
bad design.

Chan, the pharmacist, didn’t notice the “mg/kg” when he

saw “160” only a few minutes after texting Lucca to order
just that dose. Also, by a terrible coincidence, when you
multiply 160 mg/kg by 38.6 kg, you get 6,160 mg which
contains the number “160”. This is “confirmation bias”.

… Pablo did survive his 38-fold overdose of an antibiotic, thanks to

rapid rescue actions. However, the EPIC design was updated and
policies were amended. A lesson in medication errors begins …
Answers: d, a, b, b, d

May 2016 Page 3