A 5-letter fix for medication errors

RaDonda Vaught's conviction for a fatal medication error is drawing newfound attention to the technological vulnerabilities of electronic medication cabinets, Kaiser Health News reported April 29.

Ms. Vaught was convicted March 25 of criminally negligent homicide and abuse of an impaired adult for a fatal medication error she made in December 2017 while working as a nurse at Vanderbilt University Medical Center in Nashville, Tenn. Legal documents show Ms. Vaught overrode an electronic medication cabinet after failing to locate the sedative Versed. She had typed "VE" into the search function, not realizing the drug was listed under its generic name, midazolam. After triggering the override to access a larger selection of drugs, Ms. Vaught accidentally withdrew vecuronium, a powerful paralytic. 

At least seven other instances in which hospital employees administered or nearly administered the wrong drug after typing three letters or fewer into medication cabinets have occurred since 2019, according to KHN's analysis of documents from the Institute for Safe Medication Practices. This figure is likely a gross undercount, as hospitals are not mandated to report most drug mix-ups.

To prevent these errors from occuring, safety advocates say nurses should be required to type at least five letters of a drug's name when searching in electronic medication cabinets. Cabinet manufacturer Omnicell added the five-letter search function in 2020, though hospitals must opt in to the feature. BD, another cabinet company, plans to make the five-letter search standard on its Pyxis machines via a software upgrade later this year.

BD and Omnicell are the largest players in the medication cabinet industry, meaning most hospitals in the U.S. will have access to a five-letter search feature once BD completes its update. While the change will make it slightly less convenient to withdraw drugs — requiring nurses to know how to spell complex drug names — it will provide another layer of protection against errors. 

A five-letter search would lead to an "exponential increase in safety" when pulling drugs from electronic medication cabinets, according to Erin Sparnon, an expert on medical device failures at the nonprofit safety organization ECRI.

"The goal is to add as many layers of safety as possible," she told KHN. "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."

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