A Sad Case Revisited
In May of 2019, I wrote a blog titled “A Word of Caution in Overriding at the Electronic Drug Dispensing Cabinet" after a Vanderbilt University Hospital nurse used the override function at a drug dispensing cabinet and gave a patient Vecuronium, a paralyzing agent, when she intended to give Versed, a sedative. The patient died.
The case is back in the media because the nurse was found guilty of gross neglect and negligent homicide in the man’s death by a Tennessee criminal court. This is a tragedy and an ignorant decision. Healthcare has become much safer than it used to be by the reporting of medical errors and near misses so that they can be learned from and prevented. This case will stop many from reporting errors because of fear of retribution.
At GBMC, we follow the concept of just culture. In just culture, the only time that punishment is indicated is if the individual was consciously trying to harm someone or was knowingly breaking a rule that an individual in the same situation and organization would not have broken. In this case, the breaking of “the rule” is that overrides should not be used except in emergencies.
What is the override function? Drug dispensing cabinetry takes advantage of computerization to only allow medication to be removed for a given patient if it is on the patient’s “profile.” To be on the profile, there has to be an order from a provider and a pharmacist verification that the order is appropriate. In the Vanderbilt case, it appears that nurses frequently used the override to move more quickly without waiting for the order from a provider to be put in the system and for it to be verified by the pharmacist. When the override is used, two steps of protection for the patient are removed.
We humans make mistakes, especially when we are rushing. Organizations that understand this build systems to catch the mistakes. That’s what the official order and pharmacy verification are all about. If nurses at a hospital get the message (even if it is indirect) that speed and efficiency are paramount, then they use the override to move faster. In many hospitals, nurses frequently use the override function in situations that are not emergencies. This nurse was the unlucky one who used it and took a medication that could kill someone, and it did. The nurse was immediately devastated once she learned what she had done. She already lost her license and now she may go to jail. I am sure that she will appeal the case, but this is not right and if the case is allowed to stand, it will have a chilling effect on patient safety. Stay tuned.
This week is National Public Health Week – an annual time to acknowledge the contributions of public health.
Public health departments and workers are responsible for laws requiring the use of seatbelts, guidelines protecting clean air and water, and laws against smoking in restaurants and bars.
The theme for this year is “Public Health is Where You Are,” and it recognizes that promoting and protecting health is important to the public and to local communities. It celebrates the idea that the places we are physically, mentally, and socially affect our health. This theme is more important now than ever because of what we have learned from pandemic.
So, if you run into a public health professional, thank him or her!
For more information on National Public Health Week click here.
Earlier this week, I was proud to participate in the 33rd Quest for Excellence Conference along with Carolyn Candiello, our Vice President for Quality and Patient Safety and a number of our senior leaders. We were present for the award ceremony honoring the Baldrige recipients from the past three years. This was the first award ceremony featuring three years of Baldrige achievers!
It was a great event as it brought the Baldrige community together again to not only celebrate but also to learn from each other.
The conference had approximately 50 speakers from all sectors sharing their insights, tools, and stories with close to 1,000 attendees from the business, education, health care, nonprofit and government sectors. There was much discussion about role model best practices from current and former award recipients in all Baldrige areas.
I want to congratulate all of the recipients for the last three years who achieved this monumental recognition!
If you want to learn more about our 2020 Baldrige recognition, please visit here.
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