The Blame Game – We All Share in Responsibility for Medication Errors

The recent conviction of a Vanderbilt University Hospital nurse for the inadvertent death of a patient due to a drug mix-up has sent shock waves through the clinical community and generated significant soul-searching among healthcare workers. While the sentence handed down on 5/13 was three years of supervised probation rather than the maximum of eight years in prison, her nursing license remains revoked, and the criminal conviction remains on her record during probation. The underlying issues that can result in this tragedy include short staffing, training a student or new grad, interruptions, too many noisy electronic alerts, confusing messages, unclear labelling, pandemic exhaustion and more.

This ICU nurse was convicted last month by a Tennessee court for inadvertently administering vecuronium instead of midazolam (Versed) when prepping a patient for a scan. The neuromuscular blocker typically used to intubate a patient result in paralysis, respiratory depression, and ultimately death. There are many facts unknown to the public at this time, but a jury convicted the nurse of criminally negligent homicide and abuse of an impaired adult, a rare occurrence in the medical world.

There have been few medical/medication errors resulting in criminal conviction, outside of gross negligence or intent to harm. ISMP reported, "Though we cannot shed light on the causes of these errors, our experience with analyzing sentinel events and other medication errors strongly suggests that underlying system vulnerabilities played a role in each of the errors." A well-documented case of a two-year-old child’s death due to a pharmacist failing to detect a technician's chemotherapy mixing error resulted in a six-month jail sentence for the pharmacist and the beginning of patient safety advocacy by the father with the Emily Jerry Foundation.

"To Err is Human," the 1999 landmark publication of the Institute of Medicine, ushered in the Patient Safety movement, which advocated for a just culture that encourages reporting, finds the root cause, and improves the system, instead of blaming the clinician. The report set an important standard: "The problem is not bad people; the problem is that the system [of medical care] needs to be made safer."

There were many factors discussed during the Vanderbilt trial, including: ongoing technical challenges with the automated dispensing machine (ADM) where the medication was withdrawn; look-alike-sound-alike medication names (VEcuronium and VErsed); lack of barcode medication administration verification in the procedure area; and no pharmacist review. 

Humans are not infallible, and we thus need to design and improve our complex systems to reduce the risk of errors.  Moreover, Just Culture means treating healthcare workers with dignity and working with them to identify and mitigate risks.

Many healthcare organizations have adapted HRO (highly reliable organizations) principles, which outline a proactive "Culture of Safety" and continuous learning. Achieving HRO requires transparency and trust so that errors can be addressed without frightening employees into secrecy and giving them the power to raise their hands and stop the line so that improvements can be made to reduce future errors.

Now is not the time to be handwringing over a nurse’s conviction. We in pharmacy have the responsibility to speak up and to implement systems to reduce the risk of medication errors throughout the medication cycle. Interdisciplinary collaboration with nursing, providers, information services, and others can lead to critical improvements, including:

• Using barcode medication administration (BCMA) in all areas where medications are dispensed and administered (i.e., from receipt into stock, in and out of ADMs and carousels, and prior to administration).
• Integrating "smart pumps" with BCMA and pre-built libraries into the EMR.
• Implementing robust and easy-to-use event reporting systems.
• ADM enhancements:
  • Using five-character entry to search for medication names (many systems went from one character to three, which could have prevented the Vanderbilt situation).
  • Moving ADMs to "profile" status requires a provider order to match the medication removed, with limited override capability.
• Reducing alerts and reminders resulting in "noise" and frequent overrides in ADMs, EMRs, and smart pumps.
• Creating "smarter" alerts and hard stops that make the easy thing the right thing to do.
• Pharmacist verification for all orders (except urgent/emergent scenarios).
• Requiring a witness or second signature for high-risk medication actions.
• Implementing IV workflow software.

The criminalization of medication errors in the absence of intent is deeply concerning for the healthcare community. As pharmacists, we need to exert leadership in reducing medication errors by interdisciplinary collaboration, workflow redesign, technology implementation, and setting a safety culture where reporting is encouraged, and employees supported. We must use our unique combination of clinical, operational, and technological expertise to identify causes, design and implement solutions, and vigorously monitor for improvements.

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