More than four years ago, Tennessee nurse Radon Davot entered two letters into a hospital’s computerized medicine cabinet, selected the wrong drug from search results, and gave a patient a lethal dose.
Walter was indicted this year Extremely rare criminal trial for medical error, but the drug confusion at the center of her case is anything but uncommon. Computerized cabinets are nearly ubiquitous in modern healthcare, and the technical loopholes that made Vaught’s mistake possible persist in many U.S. hospitals.
Since Vaught’s arrest in 2019, there have been at least seven other incidents in which hospital staff searched medicine cabinets with three or fewer letters before administering or nearly administering, according to a KHN review of reports provided by KHN. wrong medicine. Institute for Safe Medication Practice, or ISMP. Hospitals are not required to report most drug mixups, so these seven incidents are undoubtedly a small fraction of a larger total.
Safety advocates say such mistakes can be prevented by requiring nurses to enter at least five letters of the drug name when searching hospital cabinets. The two largest cabinet companies, Omnicell and BD, agreed to update their machines based on the recommendations, but the only protection in effect so far is a default shutdown.
“One letter, two letters or three letters are not enough,” said Michael Cohen, chairman emeritus of ISMP, a nonprofit that collects error reports directly from medical professionals.
“E.g, [if you type] meet. Is it metronidazole? Or metformin? Cohen added. “One is antibiotics. Another is a drug to treat diabetes. This is quite a confusion. But when you see MET on the screen, it’s easy to choose the wrong drug. “
The Five-Letter Fix: Let It Hold On
Omnicell added five-letter search through a software update in 2020. But customers have to opt-in to the feature, so it may not be used in many hospitals. BD, which makes Pyxis cabinets, said it intends to develop five-letter search criteria on Pyxis machines via a software update later this year — more than 2.5 years after it first told security advocates the upgrade was coming.
Thousands of hospitals will feel the update: it will be harder to get the wrong medication out of the Pyxis cabinet, but slightly harder to get the right medication out of the Pyxis cabinet. Nurses need to correctly spell confusing drug names, sometimes in confusing medical emergencies.
Robert Wells, a Detroit emergency room nurse, said the hospital system where he works activated the safety measures on Omnicell cabinets about a year ago and now requires at least five letters. At first, Wells had difficulty spelling out some of the drug names, but over time that challenge is fading. “For me, drug use has become more of a hassle, but I understand why they go there,” Wells said. “It seems to be inherently safer.”
Computerized medicine cabinets, also known as automated dispensing cabinets, are how nearly every U.S. hospital manages, tracks, and dispenses dozens to hundreds of medications. Pyxis and Omnicell dominate almost all of the cabinet industry, so once the Pyxis update rolls out later this year, the five-letter search function should be available to most hospitals across the country. This feature may not work with older cabinets that are not compatible with new software, or if the hospital does not regularly update the cabinet software.
Hospital medicine cabinets are primarily accessed by nurses, who can search for them in two ways. One is by patient name, at which point the cabinet will display a menu of prescriptions that can be filled or updated. In more urgent cases, nurses can search the cabinet for a specific drug even if a prescription has not been submitted. As each additional letter is typed into the search bar, the cabinet refines the search results, reducing the chance of users choosing the wrong drug.
The seven drug confusions KHN found, each involving hospital staff withdrawing the wrong drug after entering three or fewer letters, were confidentially reported to ISMP by frontline health care workers since the 1990s.
Cohen allowed KHN to review the erroneous report after the editors determined the information about the hospital involved. The reports revealed a mix of anaesthetics, antibiotics, blood pressure drugs, hormones, muscle relaxants and a drug used to reverse the effects of sedatives.
In a 2019 confusion, a patient had to be treated for bleeding after taking ketorolac, a pain reliever that can cause blood thinning and intestinal bleeding, rather than ketamine, the drug used for anesthesia. A nurse took out the wrong medication from a cupboard after typing just three letters. If she is asked to search with four, no error will occur.
In another mistake, just weeks after Vaught’s arrest, a hospital employee mixed the same drugs as Vaught’s — the sedative Versed and the dangerous paralyzing agent vecuronium.
The ISMP study shows that requiring five letters almost completely eliminates such errors, Cohen said, because few cabinets contain two or more drugs with the same first five letters.
Erin Sparnon, a medical device failure expert at ECRI, a nonprofit focused on improving health care, said that while many hospital medication errors have nothing to do with medicine cabinets, a five-letter search will result in “multiplied safety” when pulling in the cabinets medicine.
“The goal is to add as many layers of security as possible,” Sparnon said. “I’ve seen it called the Swiss cheese model: you put enough cheese in a row that eventually you can’t see the holes through it.”
The five-letter search “is a really good piece of cheese,” she said.
Water, a former nurse at Vanderbilt University Medical Center in Nashville, was arrested in 2019 and found guilty of criminal manslaughter and gross neglect of a damaged adult in a controversial trial in March ‘s guilt.she up to eight years in prisonHer May 13 sentencing is expected to draw hundreds of protesters who argue that her medical errors should not be considered a crime and prosecuted.
At trial, prosecutors argued that Vaught made many mistakes and ignored obvious warning signs in using vecuronium instead of Versed. But Vought’s first and fundamental mistake, which made all the others possible, was inadvertently removing vecuronium from the cabinet after entering VE. If the cabinet needed three letters, Watt probably wouldn’t have drawn the wrong medicine.
“Ultimately, I can’t change what happened,” Watt said, describing the confusion to investigators in a taped interview played at her trial. “The best I can hope for is that things will happen and mistakes like this won’t be made again.”
After details of Vaught’s case became public, the ISMP reiterated its call for a safer search and then had “multiple calls” with BD and Omnicell, Cohen said. ISMP said that within a year, the two companies Confirm plans to adjust their cabinets according to its guidance.
In 2019, BD raised the default value for Pyxis enclosures to at least three letters, and intends to increase that to five in a software update expected “by the end of summer,” said BD spokesman Trey Hollern. Cabinet owners will be able to turn this feature off, as it “ultimately depends on the healthcare system to configure security settings,” Hollern said.
Omnicell added a “recommended” five-letter search via a software update in 2020, but the feature is retired, so its cabinets Allows searches with single letters by defaultaccording to a company press release.
Dangerous Typo: MORFINE
At least some hospitals have to activate the Omnicell security feature because they have started alerting ISMPs of workflow problems — misspellings or misspellings — made worse by asking for more letters. Omnicell declined to comment for this story.
Ballad Health, a chain of 21 hospitals in Tennessee and Virginia, launched a five-letter search this year when it installed new Omnicell cabinets.
CEO Alan Levine said enabling security features after the Vaught case was an easy option, but the transition exposed an unpleasant truth: Many people, even trained professionals, spell badly. “We had people trying to spell morphine as MORFINE,” Levine said.
One of the most common problems comes in emergency rooms and operating rooms, where patients need tranexamic acid, a drug used to promote blood clotting, Ballad Health officials said. With so many nurses stuck in the closet for misspelling their medication, Ballad posted a reminder of the correct spelling by adding an S or a Z.
Even so, Levine said Ballad will not discontinue five-letter search. With nurses “stretched” and more likely to make mistakes due to the pandemic and general staffing shortages, the feature is needed more than ever, he said.
“I think, given what happened to the nurses at Vanderbilt, a lot of [nurses] Better understand why we do it,” Levine said. “Because we are patients and we are trying to protect them. “
Some nurses are still not convinced.
Michelle Lehner, a nurse at a suburban Atlanta hospital who launched the five-letter search last year, said she thinks hospitals would be better served by isolating dangerous drugs like vecuronium, rather than making searches for all other drugs a chore. complex. The five-letter search, while well-intentioned, could slow nurses down so much that they do more harm than good, she said.
For example, Reiner said she retrieved Solu-Medrol, an anti-inflammatory drug, from a cabinet with a safety feature about three months ago. Lehner entered the first five letters of the drug’s name, but couldn’t find it. She searched for the generic name methylprednisolone but still couldn’t find it. She said she called the hospital pharmacy for help but couldn’t find the medicine either.
Nearly 20 minutes later, Lehner abandoned the dispensing cabinet and fetched medication from the unpowered “old-fashioned” medication carts that hospitals typically set aside for power outages.
Then she realized her mistake: she forgot the hyphen.
“If this were a situation where we needed emergency dosing,” Reiner said, “that would be unacceptable.”
KHN (Kaiser Health News) is a national newsroom that provides in-depth news coverage on health issues.Along with policy analysis and polling, KHN is one of the top three operating programs in the U.S. KFC (Kaiser Family Foundation). KFF is a donating non-profit organization that provides information on health issues to the state.
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