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May 2, 2022

The 'technological vulnerability' that can lead to medical errors

Daily Briefing

    In March, former nurse RaDonda Vaught was prosecuted for the death of a patient after she withdrew the wrong vial from an electronic medication cabinet—a "technological vulnerability" that exists in many U.S. hospitals, Brett Kelman reports for Kaiser Health News.

    Use IT to improve medication management

    A fatal medical error

    In 2017, former Vanderbilt University Medical Center (VUMC) nurse RaDonda Vaught withdrew a vial from an electronic medication cabinet and administered the drug to Charlene Murphey, a 75-year-old patient.

    Unfortunately, instead of grabbing Versed, a sedative to help calm Murphey before she underwent a scan, Vaught accidentally grabbed vecuronium, a powerful paralyzer that stopped the patient's breathing and left her brain dead before the error was discovered. Murphey ultimately died on Dec. 27, 2017.

    Vaught was criminally charged with reckless homicide and gross neglect of an impaired adult. During the trial, Vaught's attorney, Peter Strianse, argued that Vaught was being used as a "scapegoat" for problems related to VUMC's medication cabinets.

    Leanna Craft, a nurse educator at the neuro-ICU unit at VUMC, said it was common for nurses to override the system to get drugs, as there were often delays in retrieving medications from the automatic drug dispensing cabinets.

    However, Terry Bosen, VUMC's pharmacy medication safety officer, testified that while VUMC had some technical errors with its medication cabinets in 2017, those issues were fixed weeks before Vaught used the wrong medication on Murphey.

    Donna Jones, a nurse legal consultant, testified that Vaught violated the standard of care nurses are expected to maintain. Vaught not only grabbed the wrong medication but also failed to read the name of the drug, notice a red warning label on the medication, and stay with the patient to see if they had an adverse reaction, Jones said.

    The jury ultimately found Vaught guilty of gross neglect of an impaired adult and negligent homicide but acquitted her of reckless homicide.

    Prevalence of medical cabinet mix-ups—and what to do about them

    According to Kelman, mistakes involving electronic medication cabinets are "anything but rare."

    "Computerized cabinets have become nearly ubiquitous in modern health care, and the technological vulnerability that made Vaught's error possible persists in many U.S. hospitals," he says.

    According to a Kaiser Health News review of reports provided by the Institute for Safe Medication Practices (ISMP), since Vaught's arrest in 2019, there have been at least seven other reports of hospital workers who searched medication cabinets with three or fewer letters and then administered or almost administered the wrong drug.

    However, because hospitals are not required to disclose most drug errors, the seven reported incidents are likely "a small sampling of a much larger total," Kelman writes.

    Typically, hospital medication cabinets are accessed by nurses, who can search them either by patient name or, in urgent situations, by drug name. "With each additional letter typed into the search bar, the cabinet refines the search results, reducing the chance the user will select the wrong drug," Kelman writes.

    Safety advocates have argued that these types of errors could be prevented by requiring workers to type in at least the first five letters of a medication's name when searching hospital cabinets.

    "One letter, two letters, or three letters is just not enough," said Michael Cohen, the president emeritus of ISMP.

    "For example, [if you type] M-E-T. Is that metronidazole? Or metformin?" Cohen added. "One is an antibiotic. The other is a drug for diabetes. That's a pretty big mix-up. But when you see M-E-T on the screen, it's easy to select the wrong drug."

    According to Erin Sparnon, an expert on medical device failures at ECRI, even though many hospital drug errors are not related to medication cabinets, a five-letter search requirement would lead to an "exponential increase in safety" when selecting drugs from cabinets.

    "The goal is to add as many layers of safety as possible," Sparnon said. "I've seen it called the Swiss cheese model: You line up enough pieces of cheese and eventually you can't see a hole through it."

    Notably, Omnicell and BD, the two largest electronic medication cabinet companies, have agreed to update their machines to mirror these recommendations. BD said it intends to make five-letter searches standard on its machines through a software update later this year. And Omnicell added a five-letter search with its 2020 software update, but customers must opt in to the feature, so it is "likely unused in many hospitals," Kelman writes.

    But Ballad Health, a chain of 21 hospitals in Tennessee and Virginia, activated the five-letter search this year. CEO Alan Levine said it was an easy choice to engage the safety feature, particularly after the Vaught case. However, Levine acknowledged that many people are bad spellers, so the additional required letters sometimes lead to delays.

    Some nurses say they believe hospitals should isolate dangerous medications like vecuronium, instead of complicating searches for all other drugs. Michelle Lehner, a nurse at an Atlanta hospital with the five-letter search, said while they are well-intentioned, the five-letter searches might slow nurses down so much that it causes more harm than good in emergency situations.

    However, Levine said Ballad would not deactivate the five-letter search. Additionally, because of widespread staffing shortages, nurses are "stretched" and more likely to make a mistake, so the feature is needed more than ever, he said.

    "I think, given what happened to the nurse at Vanderbilt, a lot of [nurses] have a better appreciation of why we are doing it," he said. "Because we're trying to protect them as we are the patient." (Kelman, Kaiser Health News, 4/29)

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