Well that is depressing and a tragic case. While testifying before the nursing board last year, foreshadowing her defense in the upcoming trial, Vaught said th

Well that is depressing and a tragic case. 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. Murphey's care alone required at least 20 cabinet overrides in just three days, Vaught said. "Overriding was something we did as part of our practice every day," Vaught said. "You couldn't get a bag of fluids for a patient without using an override function." This clearly speaks to a larger systems issue and highlights a problem with the way medical software is designed to deflect liability from the hospital to individual employees. Why is a nurse able to get a paralytic agent from a PYXIS or similar machine outside of critical care? That falls on the hospital, pharmacy, and the nurse in terms of responsibility. Clearly she should never work in healthcare again from incompetence but if she burns due to this being criminal: everyone else above her that lead to this should burn too. When near every interaction flags the same alert you become numb to it. If you are involved in this field I caution you: get some actual clinicians and stakeholders involved early even if your customer is the hospital because the priorities are different. I know critical care nurses that get flagged on almost every medication with overrides and alerts because it is physically delivered late and they have more than one patient. The system don't measure the metric of when the medication actually arrives on the ward rather when it is ordered and delivered so fundamentally almost everything is late. What are you going to do? Not take care of your other patients, balance priorities or will the time and medication into place? It's a systems issue of being under resourced and still having to deliver care. As a physician I run into a version of this every day in my clinical practice with alerts for interactions and pharmacy faxes for interactions that are clinically irrelevant based on a database flagging it. After a while it becomes numbing and you start to get cognitive biases. It's really not that different from the circumstances that led to the Challenger disaster.