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> When the cabinet did not produce Versed, Vaught triggered an override that unlocked a much larger swath of medications Why can the person who wants to withdr

by corobo 5y ago

> When the cabinet did not produce Versed, Vaught triggered an override that unlocked a much larger swath of medications Why can the person who wants to withdraw meds override the machine? Overrides should need at least a 2-person check, ideally a supervisor as the second > she and others say overrides are a normal operating procedure used daily at hospitals If you train people to be alert blind.. they'll be alert blind. The entire situation sucks, I hope it's determined this is a systemic issue and not the individual Can't help but think if it was a pharmacist instead of a machine this would have been prevented too

lazide 5y ago
Because that will kill someone in an urgent emergency? Those folks are generally busy somewhere else, and there are few benign drugs in these situations. There are also a lot of legitimate urgent situations where an extra minute or two can get someone killed who otherwise would not be.
- corobo 5y ago
  It killed someone in a non-urgent non-emergency as it stands Crash carts and the room in general have all the meds needed to handle urgent issues don't they? You don't often see someone crashing and a nurse running off to grab a script
  - lazide 5y ago
    For the essential basics? Yes. Something I've personally seen when I was doing my EMT clinicals was a geriatric stroke patient came in (time is key here), and staff struggling to get the anticoagulants and another medicine I can't remember (but an important part of the stroke treatment protocol) from the machine in time - which they ended up not being able to do, as no one was around who had the countersigning authority in time. Which was at that point past the time the patient really needed it. They still got it, and who knows if it was the deciding factor or not for the patient. The stent they later tried to install also failed during installation after a rather large dose of radiation to the patient, so it was unfortunately just not their day. It was a sad situation all the way around. A lot of these processes are designed as CYA/risk aversion methods (which make sense from that perspective), but then also have the unstated goal of allowing cutting already overworked staff to the bone. And have the secondary effect of having people get even more exhausted, and make even more dumb mistakes, and also get blocked when it is a legitimate need by a process/approval. Though admin's ass is covered (as long as no one thinks about it too much), since the staff had to bypass a bunch of safeguards before it blew up. Missing in the press release or indictment of the staff member though is that EVERYONE had to bypass the safeguards all the time because of the sick system they were in. The only real way to address this (IMO) is to tackle the internal structural problems causing massive overwork and lack of staffing in the medical field. Good luck with that though.
nonfamous 5y ago
The nurses were explicitly trained to ignore overrides, because they were required so often: >> While testifying before the nursing board last year, foreshadowing her defense in the upcoming trial, Vaught said that at the time of Murphey's death, Vanderbilt was instructing nurses to use overrides to overcome cabinet delays and constant technical problems caused by an ongoing overhaul of the hospital's electronic health records system. As for missing the warning on the vial cap, were nurses trained to look for messages there? I can easily imagine that the process of extracting medicine into a syringe would become so routine that an unusual exception like this could be missed without some kind of check process.

by corobo 5y ago

lazide 5y ago

Because that will kill someone in an urgent emergency? Those folks are generally busy somewhere else, and there are few benign drugs in these situations. There are also a lot of legitimate urgent situations where an extra minute or two can get someone killed who otherwise would not be.

corobo 5y ago
It killed someone in a non-urgent non-emergency as it stands Crash carts and the room in general have all the meds needed to handle urgent issues don't they? You don't often see someone crashing and a nurse running off to grab a script
- lazide 5y ago
  For the essential basics? Yes. Something I've personally seen when I was doing my EMT clinicals was a geriatric stroke patient came in (time is key here), and staff struggling to get the anticoagulants and another medicine I can't remember (but an important part of the stroke treatment protocol) from the machine in time - which they ended up not being able to do, as no one was around who had the countersigning authority in time. Which was at that point past the time the patient really needed it. They still got it, and who knows if it was the deciding factor or not for the patient. The stent they later tried to install also failed during installation after a rather large dose of radiation to the patient, so it was unfortunately just not their day. It was a sad situation all the way around. A lot of these processes are designed as CYA/risk aversion methods (which make sense from that perspective), but then also have the unstated goal of allowing cutting already overworked staff to the bone. And have the secondary effect of having people get even more exhausted, and make even more dumb mistakes, and also get blocked when it is a legitimate need by a process/approval. Though admin's ass is covered (as long as no one thinks about it too much), since the staff had to bypass a bunch of safeguards before it blew up. Missing in the press release or indictment of the staff member though is that EVERYONE had to bypass the safeguards all the time because of the sick system they were in. The only real way to address this (IMO) is to tackle the internal structural problems causing massive overwork and lack of staffing in the medical field. Good luck with that though.

nonfamous 5y ago

The nurses were explicitly trained to ignore overrides, because they were required so often: >> While testifying before the nursing board last year, foreshadowing her defense in the upcoming trial, Vaught said that at the time of Murphey's death, Vanderbilt was instructing nurses to use overrides to overcome cabinet delays and constant technical problems caused by an ongoing overhaul of the hospital's electronic health records system. As for missing the warning on the vial cap, were nurses trained to look for messages there? I can easily imagine that the process of extracting medicine into a syringe would become so routine that an unusual exception like this could be missed without some kind of check process.