The Simple Thing Hospitals Can Do to Prevent Serious Drug Mistakes 2022-04-28 06:27:00


Safety advocates say such errors can be prevented by requiring nurses to type at least five letters of the drug’s name when searching hospital lockers. The two largest vault companies, Omnicell and BD, have agreed to update their devices in line with these recommendations, but the only protections that have gone into effect so far have been turned off by default.

“One, two, or three letters is not enough,” said Michael Cohen, president emeritus of ISMP, a nonprofit that collects error reports directly from medical professionals.

“for example, [if you type] he met. Is this metronidazole? Or metformin? “One is an antibiotic,” Cohen added. The other is a medicine for diabetes. This is a very big confusion. But when you see MET on your screen, it’s easy to spot the wrong drug. “

Five letter fix: Make it stick

Omnicell added a five-character search with a software update in 2020. But customers must subscribe to the feature, so it likely won’t be used in many hospitals. BD, which makes Pyxis cabinets, said it intends to perform standard five-character searches on Pyxis hardware through a software update later this year — more than two and a half years after safety advocates were first told that an upgrade was coming.

This update will appear in thousands of hospitals: it will be much more difficult to pull the wrong medication out of Pyxis lockers, but it will also be more difficult to pull the right medication. Nurses will need to spell confusing drug names correctly, sometimes in chaotic medical emergencies.

Robert Wells, an emergency room nurse in Detroit, said the hospital system he works in activated protection on Omnicell’s cabinets about a year ago and now requires at least five characters. Wells struggled to spell some of the drug names at first, but that challenge fades over time. “For me, drug withdrawal has become a bigger problem, but I understand why they go there,” Wells said. “It seems inherently safer.”

Computerized drug cabinets, also known as automated dispensing cabinets, are the way nearly every hospital in the United States manages, tracks, and dispenses dozens to hundreds of medications. Pyxis and Omnicell account for nearly all of the locker industry, so once the Pyxis update rolls out later this year, the five-character search feature should be within reach of most hospitals in the country. The feature may not be available on older lockers that are incompatible with new software or if hospitals do not update their locker software regularly.

Hospital medicine cabinets are mainly accessed by nurses, and they can look for them in two ways. One is in the patient’s name, at which point the cabinet provides a list of available prescriptions to fill or renew. In more urgent situations, nurses can search cabinets for a specific drug, even if a prescription has not yet been provided. With each additional character typed into the search bar, the locker improves search results, reducing the chance of the user choosing the wrong drug.

The seven drug mixing cases identified by KHN, each involving hospital staff members who pulled the wrong medication after typing it in three fewer letters, were reported covertly by frontline health care workers to the ISMP, which assigned error reports collectively. since the nineties. .

Cohen allowed KHN to review the error reports after revising the information that identified the hospitals involved. Those reports revealed a mixture of anesthetics, antibiotics, blood pressure medications, hormones, muscle relaxants, and a drug used to reverse the effects of sedatives.

Our nursing workforce will continue to collapse if changes are not made

In a 2019 complication, a patient had to be treated for bleeding after being given ketorolac, a pain reliever that can cause blood-thinning and gastrointestinal bleeding, instead of ketamine, a drug used in anesthesia. A nurse pulled the wrong drug from the cupboard after typing it in just three letters. The error would not have occurred if she had been asked to search with four.

In another mistake, reported just weeks after Vatot’s arrest, a hospital employee mixed in the same drugs as Vote — Versed, a sedative, and vecuronium, a dangerous paralytic.

Cohen said ISMP research indicates that requiring five letters will almost completely eliminate such errors because few cabinets contain two or more drugs with the same first five letters.

Even though many drug errors in hospitals have nothing to do with drug cabinets, the five-letter research would lead to a “massive increase,” said Erin Sparnon, an expert on medical device failures at ECRI, a nonprofit focused on improving health care. In Safety” when withdrawing medications from cabinets.

“The goal is to add as many layers of security as possible,” said Sparnon. “I’ve seen it called the Swiss cheese model: You line up enough cheese and in the end you can’t see a hole through it.”

The five-letter search, she said, is “a good piece of cheese.”

Foote, a former nurse at Vanderbilt University Medical Center in Nashville, was arrested in 2019 and convicted of murder for criminal negligence and gross negligence of a disabled adult during a controversial trial in March. she It can be up to eight years in prison. Her May 13 sentencing is expected to attract hundreds of protesters who feel her medical error should not have been prosecuted as a crime.

At the trial, prosecutors argued that Vaught made many mistakes and ignored obvious warning signs while taking vecuronium instead of Versed. But Foote’s first founding mistake, which made all others possible, was inadvertently pulling vecuronium from the treasury after writing only VE. If the locker had ordered three letters, Vout likely wouldn’t have pulled the wrong medication.

“At the end of the day, I can’t change what happened,” Fatout said, describing the error to investigators in a taped interview played during her trial. “The best I can hope is for something like this to happen, so a mistake like this can never be made again.”

Cohen said that after details of Vault’s case became public, ISMP renewed its calls for safer searches and then made “multiple calls” with BD and Omnicell. ISMP said that within a year, both companies Confirmed plans to modify their lockers According to his directions.

A BD spokesperson said: Hollern said locker owners will be able to turn this feature off because “it is ultimately up to the healthcare system to configure the security settings.”

Omnicell added a five-character ‘recommended’ search through a software update in 2020 but left the feature disabled, so its lockers Allow one-letter search by defaultaccording to a company press release.

Serious misspellings: Morphine

At least some hospitals must have activated the Omnicell security feature because they started alerting ISMP to workflow problems – misspellings or typos – that were exacerbated by requiring more characters. Omnicell declined to comment for this story.

Ballad Health, a chain of 21 hospitals in Tennessee and Virginia, has activated the five-letter research while installing new Omnicell cabinets this year.

CEO Alan Levine said it was an easy choice to use the safety feature after the Vaught case, but the move revealed an unfamiliar truth: Lots of people, even highly trained professionals, are bad spellers. “We have people trying to spell morphine as morphine,” Levine said.

Ballad Health officials said one of the most common problems arose in emergency rooms and operating rooms where patients needed tranexamic acid, a drug used to promote blood clotting. Many nurses in cabinets mistakenly misspelled the drug by adding an S or Z as Ballad posted reminders of the correct spelling.

However, Levine said Ballad won’t disrupt the five-character search. He said that due to the pandemic and widespread staff shortages, nurses are “under pressure” and more likely to make a mistake, so this advantage is needed more than ever.

“I think, given what happened to the nurse in Vanderbilt, a lot of [nurses] “We have a better appreciation for why we’re doing this,” Levine said. “Because we’re trying to protect them because we’re patient.”

Some nurses are still not convinced.

Michelle Lehner, a nurse at a suburban Atlanta hospital who activated the five-letter search last year, said she believes hospitals would be better served by isolating dangerous drugs like vecuronium, rather than complicating the search for all other drugs. She said the five-letter research, while well-intentioned, may slow the nurses’ work so much that it does more harm than good.

For example, Lehner said she went about three months ago to retrieve an anti-inflammatory drug, Solu-Medrol, from a safe with a locker. Lehner wrote the first five letters of the drug’s name but could not find it. I searched for the generic name, methylprednisolone, but still couldn’t find it. She said she called the hospital pharmacy for help, but she couldn’t find the medicine either.

Roughly 20 minutes later, Lehner abandoned the medicine dispensing cabinet and pulled the medicine from the unpowered “old school” medicine cart that the hospital usually keeps for power outages.

Then she realized her mistake: she forgot the hyphen.

“If this had been a case where we needed to give the drug urgently, that would have been unacceptable,” Lehner said.

KHN (Kaiser Health News) is a national newsroom that produces in-depth journalism on health issues. Along with policy analysis and survey, KHN is one of the three major drivers of KFF (Kaiser Family Foundation). KFF is a non-profit organization that provides information about the nation’s health issues.