3 Strategies for Mitigating Medication Dispensing Cabinet Risks

On March 25th 2022, former Vanderbilt University Medical Center nurse was found guilty of criminally negligent homicide and abuse of an impaired adult in Davidson County Court. This case, and its verdict, are landmarks in criminal prosecution of healthcare providers for medical errors. As we look at this unfortunate situation, we would be remis not to develop extended safety and compliance measures.

What happened:

On December 27, 2017, a patient was scheduled to receive a dose of Midazolam (brand name Versed) prior to undergoing an MRI scan. Midazolam (Versed) is a commonly-used injectable sedative used to treat anxiety. Nurse Vaught attempted to remove the medication from the automated drug dispensing cabinet (Accudose). She searched for the item by entering “VE” as dispensing cabinets allow searching for medications by brand or generic names, expecting to find “Versed”. According to Vaught, the medication did not appear under the patient’s profile in the dispensing device. This led her to use the override function, which allows nurses to remove a broad selection of medications without requiring an order from a prescriber. She typed “VE” again, and the first item to appear on the list was vecuronium, which is a potent paralytic agent used for intubations and anesthesia. With this item appearing first alphabetically, the nurse removed it without paying attention to the name.

Nurse Vaught proceeded to reconstitute (add diluent) to the vecuronium powder vial, draw the solution into a syringe, and administer the dose to the patient, a 75-year-old female. The patient was found unresponsive about 30 minutes after the dose was given. Charlene Murphey was resuscitated, but never regained consciousness, and tragically passed away the following day when life support was withdrawn.

How automated drug dispensing cabinets work:

Computerized cabinets such as Pyxis, Omnicell, and Accudose are interfaced to the hospitals electronic medical record (EMR)—Vanderbilt uses Epic. The dispensing system receives patient profiles and medication orders from the EMR. Then nurses retrieve medications by logging into the dispensing system when a dose is due, logging in (typically by fingerprint), selecting the patient, then selecting the order and removing the medication tied to it. Medications may only be removed under an order after a pharmacist has verified the order is safe and appropriate, and that the correct medication is assigned to the order.

However, there are some situations that require nurses to override medications from the dispensing system. Such cases include codes in the emergency department, when there is not time to enter patient information and orders into the EMR. However, overriding is often used on routine orders as a workaround when technological problems prevent orders from crossing from the EMR to the dispensing cabinet. Both EMRs and dispensing systems involve an incredibly intricate array of settings to align in order to function properly, and these settings are managed by various departments including pharmacy, IT, and clinical informatics. Unfortunately, many facilities routinely experience issues with orders and patient profiles not crossing from the EMR to their dispensing cabinets. Throughout the Vanderbilt trial, overrides resulting from interface delays were a common occurrence surrounding the time of the incident. At that time, Vanderbilt was overhauling their Epic EMR system, which led to delays in order entry, pharmacist verification, and communication between the Epic and Accudose.

The five rights:

Nurses are trained to stop and consider the “five rights” of medication administration every time a dose of medication is administered:
1. Right Patient
2. Right Drug
3. Right Dose
4. Right Route
5. Right Time

Just culture:

Most health care systems follow a guiding principle called “just culture”. The cornerstone of just culture is that ultimate responsibility for safe patient care lies with the system, not the individual. Throughout this ordeal, Vanderbilt shied away from public comment and system-wide responsibility for Murphey’s death. Vaught’s conviction in criminal court deals a blow to just culture. The precedent set by this case shifts liability and responsibility from the system to the individual. Medication Review pharmacists play an integral role in upholding just culture within our client hospitals, and we still believe it is the right approach to patient safety. The outcome of this case reinforces the seriousness of our responsibility to protect front-line clinicians from being able to make mistakes like this in the first place.

Mitigation strategies:

Each hospital maintains a list of medications approved for override. Typically, medications on an override list must treat a critical medical condition, and must have a fast onset of action. By law, the list is reviewed by pharmacy managers and medical directors annually. Since midazolam and vecuronium are both used for intubation, both would be expected to appear on a hospital’s override list.

With that being said, here are a few ways we can help improve safe use of the override function:

1. Medication-specific alerts: Most modern dispensing systems allow pharmacist administrators to require an alert message to appear at the med station when nurses access certain medications. For example, when a nurse accesses vecuronium and other paralytics, a message can display stating “WARNING: PARALYTIC AGENT. LOOK-ALIKE/SOUND-ALIKE POTENTIAL. IS THIS THE MEDICATION YOU INTEND TO REMOVE?” Responses may even be required in order for the nurse to proceed with pulling the medication.

2. Reduction of alert fatigue: Most providers, nurses, and pharmacists have encountered alert fatigue. In an abundance of caution, electronic medical records are often programmed to pop up an excessive amount of alerts including interactions between drugs, foods, medical conditions, etc. While these alerts have their place, most are not clinically significant and only serve to drown out the important alerts. We believe that reducing insignificant programmed alerts in the EMR actually improves the effectiveness of intentionally designed alerts targeted at preventing real patient harm.

3. According to Kaiser Health News, Omnicell and Pyxis (the two largest vendors of medication dispensing systems) have issued statements that they will be updating their platforms to require 5 letter searches in order to populate any medications in an override list, rather than just two letters as is currently the case.

Nothing is more important than patient safety. Medication Review remains committed to preventing medication errors using a top-down approach. As we become increasingly dependent on software and technology to guide healthcare and other industries, it is imperative that we strive for redundancies in our safety systems. One of the reasons the airline industry has an exceptional safety record is that pilots and air traffic controllers are taught to trust their instrumentation, and that there are safeguards, backups, and redundancies built into those instruments. Health systems are no different, and require an incredible amount of expertise and dedication to ensure a safe patient visit.