The computerized medicine cabinet controversy: How a few letters can harm patients and nurses

Sometimes, one small act can make everything go wrong. In the case of administering medicine to hospital patients, it could be typing just two or three letters. A recent, troubling MedCity News article sheds light on an issue many laypersons may not be aware of. In most US hospitals, medication is stored in computerized cabinets that require typing the beginning letters of their name to be dispensed. This system has obvious advantages for hospital administration, since it’s a form of instant, automated record-keeping that shows which medication was given to which patient, when, and by whom. But there is a very, very dark side to it: There are several reported cases (and probably many more that have gone unreported) of patients being given the wrong drug - sometimes with deadly results. In 2017, RaDonda Vaught, a nurse who was then working at Nashville’s Vanderbilt University Medical Center, typed the first letters of a medication she was looking for into the hospital’s computerized cabinet. But many medications share the same first two or three letters. In this case, after she quickly typed “V-E” into the computerized cabinet, Vaught was given vecuronium from the computerized cabinet, instead of Versed. This confusion ultimately led to the death of the patient Vaught treated with the incorrect drug. In May of this year, Vaught, whose case has sparked conversation and controversy in the medical community, was given three years’ probation and has been banned from working in the medical field. This is a much lighter punishment than many had been expecting - but a lot worse than many doctors are given for malpractice. That there is any punishment at all for Vaught is unfair, many advocates and fellow nurses claim. After all, she made an error that was essentially assisted by a faulty system. A few years after Vaughn’s fatal mistake, Omnicell and BD, the makers of the majority of computerized cabinets in US hospitals, have implemented updates to their software that require typing in the first five letters of a medication, instead of the first three. This will dramatically reduce - hopefully even eliminate - errors like the kind Vaughn made. However, not all hospitals have updated their software or implemented the change. There are various reasons for this, including the fact that some cabinets are too old to be compatible with the update. But one explanation that comes up often is that while the five letter system is indisputably safer (for both patients AND nurses, who won’t risk harming patients or incarceration), it can also be more complicated to use. Ballad Health CEO Alan Levine has found, for instance, that despite their extensive experience and training, many medical professionals aren’t good spellers and have a hard time entering the correct first five letters. When you consider terms like “tranexamic acid”, this isn’t so hard to understand. Sometimes, spelling isn’t even the problem. Nurse Michelle Lehner reports that she was once looking for Solu-Medrol, a drug she’s very familiar with. But when she entered the first five letters into the system, no results came up. It turned out that the drug name contains a hyphen, which the system recognized as the fifth letter. When accessing medication is often crucial for patient survival, delays like these could also risk lives. Unfortunately, there doesn’t seem to be an easy fix for this issue for now, leading some hospitals to maintain the old three-letter system or allow workers to disable letter requirements entirely- at everyone’s peril.

Others have simply found more old-fashioned solutions; for instance, Levine says that one drug is so hard for his team to spell that he’s simply posted paper reminders of the correct spelling near computerized cabinets in several different hospitals. Hopefully, with time, the cabinets’ manufacturers - or some outside savior - will find a way to make computerized medicine cabinets safer without sacrificing efficiency. In a sense, one good thing may have come of Vaughn’s tragic mistake: It’s put this issue into the spotlight. As Vaught herself said in a recorded interview: “Ultimately, I can’t change what happened. The best I can hope for is that something will come of this so a mistake like that can’t be made again.”

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