I had seen countless patients go home with prescriptions for 5mg of Oxycodone. It was the typical dose for our adult patients, but this time it had been written for a 3-year-old girl. How did this happen? How did the provider not catch that 5mg would be an overdose for this small child? How many times had this happened before and not been caught?
It is easy to ask these questions with judgment when someone else makes a mistake. But who of us in healthcare hasn’t made a mistake? I know I have. And while I am thankful that my mistakes were not fatal, it is terrifying to think that what happened to RaDonda Vaught could happen to any of us. For those who are not familiar with this case, Vaught was a nurse at Vanderbilt University Medical Center who administered the wrong medication which resulted in a patient’s death in 2017. Although Vaught reported her mistake as she was supposed to, she ended up being criminally charged and sentenced to three years of supervised probation.
So how does someone give or order the wrong medication and how can we prevent it?
We can look at James Reasons’ Swiss Cheese model of accident causation to better understand that mistakes, errors, and accidents often happen when the weakest parts of an organization’s defenses against risk line up like the holes in slices of Swiss cheese, thus allowing the mistake, error, or accident to pass through. In Vaught’s case, a combination of human and technological factors contributed to her medication error. According to Attorney General Glenn Funk, some of these contributing factors included “Vaught overriding the system, never visually checking the medication, disregarding the sticker that read ‘Warning: Paralyzing Agent’ and not monitoring the patient’s reaction to the drug”.
While these are legitimate things to point out, let's take a closer look at the practice of overriding the medication system. According to Vaught’s attorney, overriding medications was a common practice amongst nurses at Vanderbilt University Medical Center due to communication delays between different software systems. When Vaught saw that the ordered medication had not yet populated into the patient’s profile in the automated medication dispensing cabinet, she began searching for the medication by typing in the first two letters of the medication’s brand name: “VE.” However, instead of selecting Versed, a sedative that was supposed to help the patient’s anxiety, she selected the medication at the top of the list which was vecuronium, the generic name for a paralytic agent.
Those of us who pull and administer medications have all been in a scenario before where you just want to get the medication to the patient as fast as you can. From wanting to quickly alleviate severe pain to needing, increasing incredibly low blood pressure, or decreasing nausea in a post-op patient, we have all come across this scenario. What are some ways we, and the system, can help to navigate these tough situations when they come about?
Unfortunately, searching for and selecting the wrong medication from a dispensing cabinet has not been an isolated incident. Since 2019, at least seven other incidents have been reported to the Institute of Safe Medication Practices (ISMP) of wrong medications being administered or almost administered that were searched for using three or fewer letters in an automated medication dispensing cabinet.
In addition to medication dispensing cabinets, other forms of technology have gained a role in healthcare practice, including electronic health record (EHR) systems, medication barcode scanning, and electronically sending prescriptions to pharmacies. While such technology has added more layers of defense to preventing errors, like slices of Swiss cheese these technological layers also have holes in them that we must be diligent to fill.
When it comes to searching for medications in a dispensing cabinet, safety advocates recommend typing in at least the first five letters of a medication’s name. The more letters that are inputted into the system, the more refined the results will be which should reduce the chances of selecting the wrong medication. Since medication names can be very complex, a simple alphabetical printout of the medications contained in the dispensing cabinet could be attached to the cabinet for easy reference. Although typing more letters into a system or having to find the correct spelling of medication may take more time, it could make all the difference as seen in Vaught’s case. Another feature that may enhance the safety of retrieving medications from a dispensing cabinet is having the cabinet read aloud the medication that the user selects. If the user has selected the wrong medication from the list of options, hopefully hearing the medication name will catch their attention.
Going back to my 3-year-old patient with a prescription for an inappropriately high dose of Oxycodone, how was such a prescription able to be written?
As with Vaught’s case, there were holes in both the human and technological lines of defense. Perhaps the ordering provider was not used to writing prescriptions for pediatric patients. Perhaps our EHR was not equipped with the safety requirements specified by the American Academy of Pediatrics (AAP).
Regardless of what the provider was used to, two AAP requirements would have helped to prevent this prescription error:
Fortunately, in this case, a second human line of defense was able to catch the prescription error before harm could reach the child.
Stories of mistakes in healthcare, from those that were caught in time to those that caused severe harm, testify to the importance of having multiple layers of both human and technological lines of defense to ensure the safety of our patients. No layer of protection is perfect. When it comes to caregivers, we must remember that we are all fallible members of the same team working together to provide the safest care possible for our patients. Systems and technology are not perfect either and must be continuously improved to be a help and not a hindrance to providing safe care. Similar to stacking enough slices of Swiss cheese to block out the holes in each slice, organizations must have strong human and technological lines of defense to block mistakes, errors, and accidents from passing through.
Gildon, B., Condren, M., & Hughes, C. (2019). Impact of electronic health record systems on prescribing errors in pediatric clinics. Healthcare, 7(2), 57. https://doi.org/10.3390/healthcare7020057
About Kathleen Tanaka, RN
Kathleen is a registered nurse experienced in providing post-anesthesia care for pediatric and adult patients. She's passionate about finding solutions to improve workplace functionality through department leadership roles influencing clinical practice and technology. Having recently graduated with her master's degree, she's transitioning from the bedside to a technology role to improve the delivery of healthcare through the application of healthcare informatics.