A Tragic Medication Error
In a recent article by The Institute for Safe Medicine Practices (ISMP), “Another Round of the Blame Game: A Paralyzing Criminal Indictment that Recklessly ‘Overrides’ Just Culture”, the inherent risk and prevalence of medication errors are put front and center once again. The article discusses how a nurse is facing criminal charges, jail time, and fines after her medication mistake caused the death of a patient. The charge? Reckless homicide and abuse of an impaired adult. The crime? Mistakenly administering intravenous (IV) vecuronium instead of Versed (midazolam).
Versed is routinely prescribed for patients receiving radiation to reduce claustrophobia symptoms. Its spelling looks quite similar to vecuronium, at least if you are only looking at the first couple of letters – and that’s exactly what the nurse did. She was unable to find Versed on the patient’s profile in an automated dispensing cabinet and decided to override the system. All she had to do was type “VE” into the search field and wait for the first thing to pop up. She saw vecuronium and in her haste, grabbed an IV bag of it to administer to the unaware patient.
Overrides Are a Major Threat
Overrides are a constant challenge in most healthcare organizations that, with good intentions, invest in automated dispensing cabinets. They assume the technology will reduce medication errors and bring efficiencies to the hospital. Nurses often use the override feature, which in turn can cause many problems and the ADC becomes a liability.
Beginning January 2018, the Joint Commission instituted an override assessment process as a hospital performance element. The Commission’s surveyors focus on overrides when “ADCs aren’t operating in ‘profile’ mode – that is, when the device permits staff to remove products before a pharmacist has reviewed and verified orders for those medications.” Ultimately, the Joint Commission leaves override policies to the hospital. The Joint Commission only requires that the hospital can provide evidence they have a policy in place and they are collecting and analyzing override data.
There is no reason to believe this nurse intentionally put the patient in harm’s way. She did, however, willingly remove the safeguards put into place by the hospital. She likely believed she was following orders – retrieving the proper IV for the patient. She knew the automated dispensing cabinet contained the Versed and assumed the system was mistaken when she couldn’t find it on the patient’s profile. By manually circumventing the system’s safeguards, she did break protocol and put the patient at risk, but she believed she was practicing safe medicine while following a common practice. These overrides happen daily in every hospital without any problems or even any realization that overrides can cause serious risks.
The Blame Game
The article’s author points out an increasingly concerning issue – who is responsible when medical mistakes happen? It is easy to say the nurse is at fault, for she is the one who decided to override the system, however, she was led to believe the system was put into place to protect her, the patient, and the hospital. Unfortunately, things are not always so black and white.
Most nurses in the United States feel like they are assigned too many patients to care for in one shift. Rasmussen found that nurses are overburdened with workloads and hours, forced to make split-second decisions and rush care. This may be the reason why up to 65 percent of nurses make medication errors and those are just the ones that have been reported. There are plenty of near misses and potential mistakes found just in time. Less harmful medication errors are likely underreported, perhaps because of the fear of the repercussions. Who would be willing to report their errors when they know their license, job, and freedom are at risk?
ISMP goes so far as to say they stand behind this nurse, believing her to be “the second victim” of this fatal error. Her life is ruined, let alone her nursing career. Normally, nurses enter the field with the desire to help people, not for the money. Knowing that her mistake caused the death of an innocent patient was already traumatic, but to then be criminally charged as if she did it on purpose is an injustice.
Medication Errors: A Crime?
Are criminal charges in these medication errors justified? ISMP believes they are not. As the article states, “The retrieval of the medication from the ADC via override should NOT be sufficient grounds for the nurse’s criminal indictment, as the District Attorney’s Office suggests, nor should any other “safeguards that were overridden” unless [the nurse] was well aware that she was taking a substantial and unjustifiable risk.”
The question is really whether one believes the responsibility lies on the caregiver, the administration, or the system, policies, and procedures by which the caregivers work. Fingers are staunchly pointing at each because everyone has their own opinion. ISMP and others have argued the the healthcare facility is responsible for establishing their own protocols and technologies for preventing such errors. At Talon, we agree. If hospitals can error-proof the system, the nurses aren’t put in such risky situations. Everyone makes mistakes, but if they are working in a broken system, the risk for making mistakes increases substantially. An automated dispensing cabinet won’t solve the problem if the process is broken.
Blaming the nurse only creates fear and secrecy. Blaming the system and processes, however, allow problems to surface in a safe way that can be addressed. The nurse was only doing what most nurses do everyday without repercussion. We only hear of the mistakes when something tragic happens, as with this case. We should be solving the root problem within the system and process, before another patient has to die from a preventable medication mistake.
Toyota’s honorary chairman, Fujio Cho, understands this well, saying, “We get brilliant results from average people managing brilliant processes – while our competitors get average or worse results from brilliant people managing broken processes.” Hospital leaders must fix the processes before they can expect their results will improve.
Fighting The Nursing Shortage
If nurses must worry that their every move could result in criminal prosecution, what will that do to the growing nursing shortage? Our nurses are the backbone of every health care facility in the nation. We need more of them, particularly if we are to care for our increasing elderly population. They must be enabled to do their jobs well, meaning they should be equipped with the proper tools and technology to care for patients. Many hospitals are working with tight margins already and further investments in modern technology can take years to approve. When patient lives, hospital reputations, and nurse retention is on the line, a relatively small investment in technology can be well worth the effort.
ISMP fears the repercussions of this case will foster a culture of secrecy, blame, and fear. Instead of solving the problem, the focus has been on determining who is at fault. Forbidding overrides is not the answer, as these overrides have proven to be effective in certain situations and we want to avoid unauthorized stockpiling of medications. What’s needed, according to the ISMP, is appropriate system design and training.
Point-of-Use or Pass-Through Cabinets Remove The Risk
The automated dispensing system is only the first line of defense. The software in the ADCs is technologically advanced and does what it was created to do. The issue is that the system for delivering medications is dependent on the wrong product mix. By segregating prescribed, scheduled medications from bulk inventory medications and storing them near the patient in a point-of-use or pass-through cabinet, the override feature may rarely be used.
Pass-through cabinets controlled by MedKey software gives pharmacies more control over what medications the nurse has access to in the first place. This is accomplished by segregating prescribed medications that already have a schedule in place, as when to administer the medicine to the patient. These segregated medications can be stored in the patient’s room, ensuring the nurse only has access to that specific patient’s medications in their exact dosages as prepared by the pharmacy. Restrictions can also be programmed into the software for specific medications and pharmacists can then receive regular reports on who is accessing these medications and when.
In the situation above, Versed, and only Versed, would have been in the cabinet at the patient’s bedside. No override feature would be needed or available to pose a risk. If dispensing the Versed were to be an emergency and an ADC must be used, the process of overriding the ADC would be so atypical, the nurse would be on high alert when overriding. It changes the process of overrides from commonplace to a rarity.
Bringing the pharmacy to the patient bedside for prescribed medications is a better way of delivering care. It not only reduces the burden on nurses, both in workflow efficiency and risk for making medication errors, but it improves quality of care and patient safety. Medication management is more accurate and less dependent on humans following strict protocols. While it isn’t the one and only solution to medication mistakes, it is a huge step in the right direction.