By How One Nurse Allegedly Gave the Wrong Medication to a Patient
Prosecutors in Davidson County, Tennessee are pressing charges against former nurse Radonda Leanne Vaught after she allegedly overrode the safeguards on an automatic electronic medicine dispensing cabinet at Vanderbilt University Medical Center, which resulted in the death of one of her patients in 2017. Steve Hayslip, the spokesman for the district attorney’s office in Davidson County, said last Wednesday that the DA is charging Vaught with reckless homicide. Vaught is due in court on February 20th. Learn more about what caused this tragic incident and what can be done to prevent mistakes like this in the future.
What Caused This Fatal Drug-Swap?
According to Hayslip, Vaught is being charged with reckless homicide because she allegedly overrode safeguards in the dispensing cabinet. She was supposed to prescribe the patient Versed, used for anesthesia, procedural sedation, trouble sleeping, and severe agitation, but instead she selected the first drug labeled under “VE”, which happened to be vecuronium, which is used to relax the muscles and keep patients still during surgery. This tragic mistake led to the death of Vaught’s patient. While details are scant, it seems Vaught simply grabbed the wrong medication, mistaking one drug labeled “VE” for another.
The Rise of Automatic Dispensing Cabinets
Automated electronic dispensing cabinets (ADCs) have been around since the 1980s, but today they’ve become common in hospitals and medical centers across the country. As of 2008, 80% of U.S. hospitals were using ADCs as opposed to manual medication dispensers. These medication distribution systems track prescription medications and are often connected to a patient’s electronic health records, so nurses can quickly request medications and check inventory levels when reviewing a patient’s file instead of having to manually search for the medication at the pharmacy.
Typically, the medications are locked in the dispensing unit, with controlled substances and other drugs being electronically tracked in the system, helping staff members improve visibility and prescription inventory control.
But as convenient as ADCs can be, studies show ADCs don’t always lower dispensing and drug administration errors. In fact, in six of the seven nursing units evaluated, studies showed an increase in dispensing errors.
How to Improve Medication Administration Safety with ADCs
While it’s unclear why Vaught grabbed the wrong medication, facilities can improve medication administration safety by incorporating the following safety features into their ADCs:
- Pharmacist Approval
When a nurse requests a certain medication for one of their patients, having a pharmacist review the request can help prevent dispensing errors. Without this feature, some nurses may not be aware of possible dispensing errors, such as duplicate drugs, dosing requirements, allergic reactions and drug contraindications.
- Maintaining Proper Inventory Levels
If medication quantities are limited in ADCs, some nurses may request drugs ahead of time to ensure patients have access to the drugs they need. But this can lead to a great deal of confusion in the workplace as nurses try to anticipate their patients’ needs. Maintaining proper inventory levels can help prevent this issue.
Storing too many different drugs in ADCs can also contribute to dispensing errors, especially if many have yet to be logged in the system.
- Proper Lighting and Medication Labeling
Putting ADCs in poorly illuminated areas with lots of foot traffic can also contribute to prescription medication errors. Nurses may be distracted or trying to complete multiples tasks at once as they request and dispense medications. Nurses are often overworked or may be suffering from fatigue, so creating a safer environment for dispensing medication can improve drug administration safety.
Having the right labeling system can also reduce dispensing errors. If multiple drugs are labeled similarly, nurses can easily request the wrong medication by mistake. Drugs often feature complicated names, and many begin with the same two or three letters, so clearly labeling these drugs can improve administration safety.
Strict Stocking Procedures
Typically, only the pharmacist should be restocking the ADC. Yet, some nurses may return unused medications to the cabinet, but this can lead to dispensing errors. Labeling each prescription with a barcode and scanning the bottle before entering it into the system can help reduce these errors, instead of having staff members restock the cabinet manually.
While the outcome of Vaught’s case is yet to be determined, facilities can help reduce drug dispensing errors by following these safety recommendations. Using ADCs to dispense drugs can be a great way to improve medication safety, but only with if these cabinets come with the right safety features.
Sources:
https://wtop.com/national/2019/02/da-nurse-charged-in-fatal-drug-swap-override-safeguard/
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3462599/
