5 ms·

This was a tragic case of how an overworked nurse accidentally killed a patient by administering the wrong medication with a similar name. The HN angle is that

This was a tragic case of how an overworked nurse accidentally killed a patient by administering the wrong medication with a similar name. The HN angle is that part of the error resulted from user experience design choices in the hospital's electronic medication cabinet. An overwhelming number of alerts were routinely displayed, leading to a form of banner blindness and frequent overrides. An overzealous autocomplete suggested the wrong drug with the same first two letters. There was apparently not a permission system in place that blocked her from administering the drug for this patient. The patient died soon after administration, and the nurse is now facing criminal prosecution for reckless homicide. Other nurses across the country are concerned, especially given their overwhelming workloads during and after covid and the frequent room for error.

rbanffy 5y ago
Overrides should never be common and whoever overlooked that was negligent in allowing the situation to get that way - and the responsibility extends to manufacturer and whoever is the vendor managing the EMR system. Blocks exist for a reason and overriding them should never be common procedure. A fire alarm that triggers every day for no reason is useless. In weeks people will ignore it and, when a fire actually happens, they'll die.
- HarryHirsch 5y ago
  At the end of the day you had a nurse administer a deadly medication that had a huge warning printed on the lid administer to a patient that didn't need it. There is a lot of systemic culpability there, patient safety at Vanderbilt is an afterthought, but that should not mean that there is no individual culpability.
  - technobabbler 5y ago
    Yep. According to the article she accepted the blame and acknowledged her mistake. But there were also a bunch of systematic factors contributing to the error. The UX stuff was actually buried very deep in the article, I just thought it was an interesting part of healthcare that's rarely discussed. The medication she administered was in a different form, even (powder instead of liquid, like kool-aid). But that still didn't stop the mistake. Everyone in healthcare right now is exhausted all the time, understaffed and overworked, and enough small errors can accumulate into major catastrophes. Didn't seem like there was a process in place to prevent this, either in software or training or day to day. She's not trying to avoid responsibility, but also, should she get prison time for a mistake vs losing her license and job? And who else in the chain of command should be held responsible? How will this ripple across the healthcare industry? We have a hard time filling nursing positions already, and the other nurses interviewed for the article all worried the same could've happened to them.
    - HarryHirsch 5y ago
      I'm teaching a nursing chemistry course right now. There's a certain kind of character who sees the course not as an opportunity to learn but as an obstacle to overcome on their way to make a living. We are trying our damnedest best to weed those out. What has happened is this: nurse tasked to administer Versed. Versed - what's that, don't care. <goes to medicine cabinet> VE-clickedy-click. Vecuronium? Dunno what's that, but it's good enough. Big warning! Medicine be dangerous! Medicine is administered, patient dies. Nurse says, mistakes were made, but Jesus loves me! Enough of that.
      - yunohn 5y ago
        > There's a certain kind of character who sees the course not as an opportunity to learn but as an obstacle to overcome on their way to make a living. You might be surprised to hear that most people you know are doing what they can to make a living. It seems like you may not see it that way, while instead making a moral judgement of who “really cares”. I understand your sentiment, but I would advise caution in such situations.
        b112 5y ago
        You can want to make a living, but also have a personality where you care why, and how things work. Where you are fascinated with the universe, and seek to know more. Some jobs are simply not for those whose personailty does not mesh. Another example would be an introvert, taking a job as an MC. Not the best fit there.
        yunohn 5y ago
        I understand your viewpoint, but even as an engineer who thinks that I care about figuring things out - oftentimes I don’t as well. It’s all really dependent on my personal/mental well-being or even systemic situation/pressures. My point being that such traits are a spectrum and can vary over time.
        5y ago
- technobabbler 5y ago
  Yeah, exactly. How did it get this bad? It can't just be this one nurse ignoring warnings. Reminds me of UAC on Windows, but with deadly consequences.
  - rbanffy 5y ago
    Unfortunately, UAC conditioned a whole lot of people to just click OK without reading (or understanding) the message.
    - eternityforest 5y ago
      Cookie prompts are probably doing the same too
xyzzy21 5y ago
After basic cardiovascular death and cancer death, the next most common is "medical errors" such as this.
dekhn 5y ago
that's not how I read the article. This nurse made a huge error and repeatedly overrode clear alert systems. The only complaint I can see is needing to type the formal name of the drug instead of the brand name.
- notreallyserio 5y ago
  That part of the article makes me wonder how often they are asked to override alerts. Is it something that they have to do for every medication? For commonly prescribed medications?
  - ZanyProgrammer 5y ago
    It's possible the particular medication management system has it as an option of some sort-only some meds can be overriden, only some users can override, or maybe some manager can turn off completely the ability to override. There's definitely a time and a place for overriding meds, and nothing in this story indicates that particular workflow is too prevalent or pervasive.
    - notreallyserio 5y ago
      It's possible, we just don't know. The prosecution doesn't seem to be saying. Really, my point is (by example) if regular medications require 4 confirmations or overrides and this one requires 5, that's a problem.
ZanyProgrammer 5y ago
> There was apparently not a permission system in place that blocked her from administering the drug for this patient. Why should there be? Versed is a Schedule IV drug, vecuronium is not scheduled-if anything, the system worked since she was able to dispense a drug that wasn't controlled as well as the drug she had permission to dispense. In the acute care space there's lots of instances where an end user will need to override something for some reason or another. It's ultimately the end user's fault for neglecting the errors.
- wl 5y ago
  > Why should there be? Versed is a Schedule IV drug, vecuronium is not scheduled-if anything DEA scheduling is supposedly about abuse potential, not safety. Vecuronium is one of the most dangerous drugs in the hospital. It's used to paralyze essentially every muscle in the body except the heart to keep a patient from moving during surgery or to get a breathing tube through spasming vocal cords. These muscles include the ones used for breathing. Most physicians aren't allowed to give it. Those that are have trained for years before they're allowed to give it independently. There are no circumstances when a nurse should be giving this drug without a physician closely supervising.

rbanffy 5y ago

Overrides should never be common and whoever overlooked that was negligent in allowing the situation to get that way - and the responsibility extends to manufacturer and whoever is the vendor managing the EMR system. Blocks exist for a reason and overriding them should never be common procedure. A fire alarm that triggers every day for no reason is useless. In weeks people will ignore it and, when a fire actually happens, they'll die.

HarryHirsch 5y ago
At the end of the day you had a nurse administer a deadly medication that had a huge warning printed on the lid administer to a patient that didn't need it. There is a lot of systemic culpability there, patient safety at Vanderbilt is an afterthought, but that should not mean that there is no individual culpability.
- technobabbler 5y ago
  Yep. According to the article she accepted the blame and acknowledged her mistake. But there were also a bunch of systematic factors contributing to the error. The UX stuff was actually buried very deep in the article, I just thought it was an interesting part of healthcare that's rarely discussed. The medication she administered was in a different form, even (powder instead of liquid, like kool-aid). But that still didn't stop the mistake. Everyone in healthcare right now is exhausted all the time, understaffed and overworked, and enough small errors can accumulate into major catastrophes. Didn't seem like there was a process in place to prevent this, either in software or training or day to day. She's not trying to avoid responsibility, but also, should she get prison time for a mistake vs losing her license and job? And who else in the chain of command should be held responsible? How will this ripple across the healthcare industry? We have a hard time filling nursing positions already, and the other nurses interviewed for the article all worried the same could've happened to them.
  - HarryHirsch 5y ago
    I'm teaching a nursing chemistry course right now. There's a certain kind of character who sees the course not as an opportunity to learn but as an obstacle to overcome on their way to make a living. We are trying our damnedest best to weed those out. What has happened is this: nurse tasked to administer Versed. Versed - what's that, don't care. <goes to medicine cabinet> VE-clickedy-click. Vecuronium? Dunno what's that, but it's good enough. Big warning! Medicine be dangerous! Medicine is administered, patient dies. Nurse says, mistakes were made, but Jesus loves me! Enough of that.
    - yunohn 5y ago
      > There's a certain kind of character who sees the course not as an opportunity to learn but as an obstacle to overcome on their way to make a living. You might be surprised to hear that most people you know are doing what they can to make a living. It seems like you may not see it that way, while instead making a moral judgement of who “really cares”. I understand your sentiment, but I would advise caution in such situations.
      - b112 5y ago
        You can want to make a living, but also have a personality where you care why, and how things work. Where you are fascinated with the universe, and seek to know more. Some jobs are simply not for those whose personailty does not mesh. Another example would be an introvert, taking a job as an MC. Not the best fit there.
        yunohn 5y ago
        I understand your viewpoint, but even as an engineer who thinks that I care about figuring things out - oftentimes I don’t as well. It’s all really dependent on my personal/mental well-being or even systemic situation/pressures. My point being that such traits are a spectrum and can vary over time.
        5y ago
technobabbler 5y ago
Yeah, exactly. How did it get this bad? It can't just be this one nurse ignoring warnings. Reminds me of UAC on Windows, but with deadly consequences.
- rbanffy 5y ago
  Unfortunately, UAC conditioned a whole lot of people to just click OK without reading (or understanding) the message.
  - eternityforest 5y ago
    Cookie prompts are probably doing the same too

xyzzy21 5y ago

After basic cardiovascular death and cancer death, the next most common is "medical errors" such as this.

dekhn 5y ago

that's not how I read the article. This nurse made a huge error and repeatedly overrode clear alert systems. The only complaint I can see is needing to type the formal name of the drug instead of the brand name.

notreallyserio 5y ago
That part of the article makes me wonder how often they are asked to override alerts. Is it something that they have to do for every medication? For commonly prescribed medications?
- ZanyProgrammer 5y ago
  It's possible the particular medication management system has it as an option of some sort-only some meds can be overriden, only some users can override, or maybe some manager can turn off completely the ability to override. There's definitely a time and a place for overriding meds, and nothing in this story indicates that particular workflow is too prevalent or pervasive.
  - notreallyserio 5y ago
    It's possible, we just don't know. The prosecution doesn't seem to be saying. Really, my point is (by example) if regular medications require 4 confirmations or overrides and this one requires 5, that's a problem.

ZanyProgrammer 5y ago

> There was apparently not a permission system in place that blocked her from administering the drug for this patient. Why should there be? Versed is a Schedule IV drug, vecuronium is not scheduled-if anything, the system worked since she was able to dispense a drug that wasn't controlled as well as the drug she had permission to dispense. In the acute care space there's lots of instances where an end user will need to override something for some reason or another. It's ultimately the end user's fault for neglecting the errors.

wl 5y ago
> Why should there be? Versed is a Schedule IV drug, vecuronium is not scheduled-if anything DEA scheduling is supposedly about abuse potential, not safety. Vecuronium is one of the most dangerous drugs in the hospital. It's used to paralyze essentially every muscle in the body except the heart to keep a patient from moving during surgery or to get a breathing tube through spasming vocal cords. These muscles include the ones used for breathing. Most physicians aren't allowed to give it. Those that are have trained for years before they're allowed to give it independently. There are no circumstances when a nurse should be giving this drug without a physician closely supervising.