3 ms·
There are some details here about the technical/software aspect of this that are interesting: https://www.medpagetoday.com/special-reports/exclusives/97822 http
by rudedogg 5y ago
There are some details here about the technical/software aspect of this that are interesting: https://www.medpagetoday.com/special-reports/exclusives/97822 https://www.medpagetoday.com/special-reports/exclusives/9782...
> Prosecutors are expected to focus on how Vaught overrode several warnings from an electronic medicine cabinet. Vaught allegedly typed in "VE" for Versed, but when nothing came up, she hit an "override" that brought up more medications, according to court documents. She searched "VE" again and the cabinet produced the paralytic vecuronium.
> Vaught had to override at least five warnings or pop-ups alerting her to the fact that she was withdrawing a paralytic, prosecutors allege. She also allegedly did not recognize that midazolam is a liquid, while vecuronium is a powder that needs to be mixed into liquid.
> During a nursing board hearing last year, Vaught stated that overrides are part of normal operating procedures.
> "Overriding was something we did as part of our practice every day," she said, according to an NPR report. "You couldn't get a bag of fluids for a patient without using an override function."
I wonder why the proper medication wasn't in the list when the Nurse searched? It's UX/UI 101 that if you nag users constantly they'll ignore your warnings as well.
It does sound like the Nurse was driving on autopilot and skipped over several things that should have made her pause while preparing the medication though.
- tomohawk 5y agoNurses get warning fatigue. They get warned about everything all the time. Medical devices are always audibly alarming. Engineers designing these machines should be required to shadow nurses for a few months.