Reckless or routine? Workarounds point of debate in nurse's trial

RaDonda Leanne Vaught faces criminal charges over a fatal medication error she made in 2017. Her trial raises important questions over medical errors, reporting and process improvement, as well as who bears responsibility for widespread use of tech overrides in hospitals. 

Ms. Vaught faces charges of reckless homicide and impaired adult abuse. In December 2017, she inadvertently injected a 75-year-old patient with a powerful paralyzer, vecuronium, when she was prescribed a sedative, Versed, at Vanderbilt University Medical Center in Nashville, Tenn. She was fired from the hospital, stripped of her nursing license and faces up to 12 years in prison if convicted. 

Ms. Vaught's use of an Accudose electronic medication cabinet is a centerpiece of the case. Documents filed in the case show Ms. Vaught first tried to withdraw Versed from a cabinet by typing "VE" into the search function, not realizing it would have been listed under its generic name, midazolam, NPR reports. When the cabinet did not produce Versed, Ms. Vaught triggered an override that unlocked a larger selection of medications, then searched for "VE" again. The cabinet then offered vecuronium.

There is debate over whether automated dispensing cabinet overrides are a reckless act or institutionalized as ordinary given the widespread use of IT workarounds among healthcare professionals. The Nashville District Attorney's Office describes this override as a reckless act and a foundation for Ms. Vaught's reckless homicide charge, while some experts have said cabinet overrides are used daily at many hospitals, according to NPR.

Ms. Vaught said that in December 2017, Vanderbilt directed nurses to use overrides to overcome cabinet delays and constant technical problems caused by an ongoing overhaul of the hospital's EHR system. She said caring for the patient who died from the medical error required at least 20 cabinet overrides in three days, NPR reports. 

Ms. Vaught's attorney, Peter Strianse, contends that Vanderbilt was struggling with a problem that prevented timely communication between its Epic EHR, medication cabinets and the hospital pharmacy, which caused "significant delays" in obtaining medication. The hospital's short-term workaround was to override the safeguards on the cabinets so staff could get drugs quickly as needed, Mr. Strianse told The Tennessean.

On March 23, a lead investigator in the case testified that state investigators found Vanderbilt University Medical Center had a "heavy burden of responsibility" for the drug error, but pursued penalties and criminal charges only against the nurse and not the hospital itself, NPR reports. Vanderbilt has received no punishment for the fatal drug error.

Michael Cohen, ScD, president emeritus of the Institute for Safe Medication Practices, and Lorie Brown, RN, past president of the American Association of Nurse Attorneys, told NPR it is common for nurses to use an override function to obtain medication in a hospital, but stressed that it should not have easy to access vecuronium even with an override. 

Dr. Cohen said that in response to Ms. Vaught's case, medication cabinet manufacturers updated their software to require the typing of up to five letters when searching for drugs during an override. Not all hospitals have implemented this safeguard.

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