by technobabbler on 3/23/22, 11:30 AM with 54 comments
by technobabbler on 3/23/22, 11:30 AM
An overwhelming number of alerts were routinely displayed, leading to a form of banner blindness and frequent overrides. An overzealous autocomplete suggested the wrong drug with the same first two letters. There was apparently not a permission system in place that blocked her from administering the drug for this patient.
The patient died soon after administration, and the nurse is now facing criminal prosecution for reckless homicide. Other nurses across the country are concerned, especially given their overwhelming workloads during and after covid and the frequent room for error.
by wl on 3/23/22, 1:45 PM
Specifically:
* Imagine being fully conscious but being unable to move or breathe. Imagine the panic as you suffocate. That's how this patient died.
* The drug the nurse intended to give (Versed) was a sedative. The standard of care for sedation includes monitoring. There was no monitoring as there should have been. A simple pulse oximeter would have caught the error before it was fatal.
* Vercuronium is especially dangerous and thus tightly controlled. Only attending anesthesiologists and emergency medicine physicians give it independently. Residents give it under supervision. The only nurses who give it are CRNAs under direct supervision. The nurse had to go out of her way to get around restrictions designed to prevent her from giving it. The drug has warnings. And she had to mix it up herself, unlike every other time she gave Versed.
by corobo on 3/23/22, 1:30 PM
Why can the person who wants to withdraw meds override the machine? Overrides should need at least a 2-person check, ideally a supervisor as the second
> she and others say overrides are a normal operating procedure used daily at hospitals
If you train people to be alert blind.. they'll be alert blind.
The entire situation sucks, I hope it's determined this is a systemic issue and not the individual
Can't help but think if it was a pharmacist instead of a machine this would have been prevented too
by dusted on 3/23/22, 12:51 PM
High pressure, intensive work comes with an inherent risk. Attempting to reduce this risk by adding additional pressure with threats of punishment to the people who do this extremely important work every day seems grotesque to me.
Reduce the pressure and intensiveness of the work as much as possible. Accept that these people are already inherently motivated not to kill others or themselves by accident or neglect.
by Gunax on 3/23/22, 1:31 PM
In short: it's the technology. That article changed my views on warnings, and I think it should be required reading for anyone designing a system with alarms and overrides.
by zeagle on 3/23/22, 1:51 PM
While testifying before the nursing board last year, foreshadowing her defense in the upcoming trial, Vaught said that at the time of Murphey's death, Vanderbilt was instructing nurses to use overrides to overcome cabinet delays and constant technical problems caused by an ongoing overhaul of the hospital's electronic health records system.
Murphey's care alone required at least 20 cabinet overrides in just three days, Vaught said.
"Overriding was something we did as part of our practice every day," Vaught said. "You couldn't get a bag of fluids for a patient without using an override function."
This clearly speaks to a larger systems issue and highlights a problem with the way medical software is designed to deflect liability from the hospital to individual employees. Why is a nurse able to get a paralytic agent from a PYXIS or similar machine outside of critical care? That falls on the hospital, pharmacy, and the nurse in terms of responsibility.
Clearly she should never work in healthcare again from incompetence but if she burns due to this being criminal: everyone else above her that lead to this should burn too.
When near every interaction flags the same alert you become numb to it. If you are involved in this field I caution you: get some actual clinicians and stakeholders involved early even if your customer is the hospital because the priorities are different.
I know critical care nurses that get flagged on almost every medication with overrides and alerts because it is physically delivered late and they have more than one patient. The system don't measure the metric of when the medication actually arrives on the ward rather when it is ordered and delivered so fundamentally almost everything is late. What are you going to do? Not take care of your other patients, balance priorities or will the time and medication into place? It's a systems issue of being under resourced and still having to deliver care.
As a physician I run into a version of this every day in my clinical practice with alerts for interactions and pharmacy faxes for interactions that are clinically irrelevant based on a database flagging it. After a while it becomes numbing and you start to get cognitive biases. It's really not that different from the circumstances that led to the Challenger disaster.
by throwawayninja on 3/23/22, 12:18 PM
This will not help the overworked state and the next issue I can see is confusing two drugs (marketing _loves_ to confuse people, given enough phonemes it would be easy to type the full name in wrong); potentially asking for a brief description of what the caregiver expects to happen, with a quick NLP pass comparing the "effect description attached to drug" paragraph and the 2-3 sentence "expected effect description from caregiver". Yes more paperwork, but saving lives is usually worth the extra effort. Everyone already knows the long-term overwork solution is cut down on admin & hire more personnel.
by kirykl on 3/23/22, 2:10 PM
by eternityforest on 3/23/22, 1:32 PM
First you select a drug, then the system estimates danger and urgency(Safer drugs often used in cases where seconds count could bypass the extra check), then the cabinet displays all the purposes one might use the drug for, along with random unrelated purposes and a text field.
If you ask for a sedative, you have to say why. And if you click an unrelated purpose, it will make you retry everything, and also show up on a report that you and your supervisor can look at to see if there are any patterns of frequently being caught.
Especially dangerous drugs could even require control room authorization, one operator could potentially supervise dozens of nurses remotely.
I'm not sure if people would get even more complacent, but it seems like errors are already common enough that it might be hard to make it worse.
by colinwilyb on 3/23/22, 2:32 PM
"Type the full name of the drug to dispense."
by xyzzy21 on 3/23/22, 1:51 PM
Or better, make sure you have processes and procedures to minimize fatality-causing errors - if others won't create them, YOU SHOULD for yourself as a professional! A VERY TRIVIAL process is having a checklist what includes: "Visually validate medication label to patient order" and even "Have one other attending nurse or doctor confirm validation". This is done by pilots as SOP!
I have ZERO sympathy for her or for "colleagues who now worry"... NONE.