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PABLO GARCIA
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
inflammation.
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?
Question
1
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.
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.
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
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!
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
breathing.
The Epic alert that Lucca received is later admitted to be
bad design.