Curbside Consult with Dr. Jayne 3/28/22

The only thing being discussed in the virtual physician lounge this weekend was the trial of Tennessee nurse RaDonda Vaught, who was found guilty of criminally negligent homicide following a medication error. Criminally negligent homicide is a lesser charge than reckless homicide, of which she was found not guilty.

For anyone who hasn’t been following the story, the short version is as follows. Vaught, who was a nurse at Vanderbilt University Medical Center, was managing a patient order for the drug Versed. The patient had been admitted to the hospital’s neurological intensive care unit following a brain bleed. The drug was ordered to help manage anxiety and claustrophobia prior to a PET scan. Vaught couldn’t find Versed in the automated medication dispensing cabinet and used an override to unlock a broader menu of drugs, leading her to obtain the drug vecuronium instead. Versed is the brand name for the sedative midazolam. Vecuronium is the generic name for the drug Norcuron, which is used to aid in “surgical relaxation” for general anesthesia or to create paralysis for patients who are on ventilators in the intensive care unit.

Vaught failed to validate the name of the drug, didn’t notice a warning on the medication vial itself, and didn’t stay with the patient after administration.

Vaught’s attorneys argued that although she admitted making errors with the medication, those errors were part of normal operations at Vanderbilt and reflect systemic dysfunction. Prosecutors alleged that she ignored multiple warning popups, including one that would have said the drug was a “paralyzing agent” and that would have required a reason for the override. Other nurses working on the same unit testified that overriding the medication dispenser was a common occurrence and that a recent EHR upgrade had created delays in obtaining medications from the cabinets. They cited organizational emails instructing nurses to override warnings to reduce delays. Additionally, there was no barcode scanner in the imaging department, where the medication was administered. A scan of the patient’s hospital ID bracelet against the medication might have prevented the fatal drug administration.

As a clinical informaticist and process improvement specialist, I think about these kinds of errors all the time. Our system of having both generic and brand names for drugs causes a lot of confusion. I trained in a residency program where we were only allowed to refer to drugs by their generic names, which probably prevented some errors by newly minted physicians. However, when I entered private practice, there was a lot to learn, as many of my patients referred to their drugs by brand name. I ran across a couple of situations where the patient was on two drugs from the same class that would have been caught had the generic names been used. Fortunately, none of the patients were harmed before we could modify their regimens.

This error also brings up the issue with “look alike” or “sound alike” drugs. In the EHR realm we’ve taken steps to manage the former with interventions such as Tall Man Lettering for drug names ,which help to differentiate names that are close. One could argue that Versed and vecuronium aren’t close other than that they both start with the letter V, but it’s important to understand the level of baseline confusion that might exist when hundreds of drugs are used within a patient care unit on any given day. The practice of medicine has become significantly more complicated over the last two decades with hospitalized patients often being “sicker” than they were in the past. Due to medical advances, patients who previously might have died are living longer, often with a dozen or more drugs to address their health conditions as well as to mitigate issues caused by the drugs themselves.

There are also issues with the setup of the automated drug dispensing cabinet. At the time, the Vanderbilt system only required two letters to be entered to access a drug menu. One organization I worked with had their cabinets set to require five letters to locate a drug. They also had all paralytic agents in a specially colored locked container to make it clear that nurses were accessing something that required additional diligence. Additionally, Vaught was administering medications outside her usual department and didn’t document the administration of the drug. Its lack of inclusion in the medical record led to a death certificate that noted a natural death following a brain bleed rather than being related to the medication administration.

Vanderbilt didn’t report the medication error to the state. Only a year later when an anonymous tip was sent to state agencies did an investigation begin.

Anyone who has practiced in a complex care environment, such as an intensive care unit, understands how even a small distraction can have significant consequences. As a sleep-deprived resident physician, zoning out even for a second could mean missing a critical part of a patient’s information. In past times, ICU nurses may have cared for one or maybe two patients. Today I see them caring for three or more patients, which certainly isn’t helping with attention issues or distraction.

In a hearing before the Tennessee Board of Nursing, Vaught stated that she was distracted while precepting a trainee, but admitted responsibility for the incident. Although this incident occurred long before the COVID-19 pandemic, I can only imagine the level of distraction that nurses faced over the last two years.

In response to this case, I hope all facilities are reevaluating their processes for overrides on automated drug dispensing cabinets and how they store critical drugs such as vecuronium. In speaking with a pharmacist friend about this case, she noted that not all hospitals have increased their search requirements to five characters as my client did. If you’re at one of those institutions, I’d encourage you to quickly prioritize an evaluation of your processes.

This case is a perfect example of the Swiss cheese model of process safety. The more holes that are present, the easier it is for a mistake to happen. When the holes are particularly large, such as when medication overrides have to happen on a daily basis, people become desensitized to the safeguards that are designed to protect patients.

Certainly there were individual actions that led to this tragedy. Policies weren’t followed and literal bright red warnings were ignored. But without the combination of circumstances, the patient would not have received the wrong medication.

Those of us on the clinical front lines have all made mistakes. Some of those mistakes become near misses because of systems that protect patients (and also us as caregivers). But some of those mistakes become true medical errors that have devastating consequences. Comments from my peers run the spectrum from “it’s all Vanderbilt’s fault” to “she deserves the death penalty.” The reality though is that we could all benefit from a closer look, as well as a slower and more thoughtful one, at how a situation like this might unfold in our worlds.

Have you ever been responsible for a medical error? What advice would you give for those who design and maintain the systems upon which you rely? Leave a comment or email me.

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