Security advocates say such mistakes could be avoided by requiring nurses to type at least five letters of a drug’s name when searching hospital cabinets. The two biggest cabinet companies, Omnicell and BD, have agreed to update their machines to these recommendations, but the only protection that has taken effect so far is disabled by default.
“One letter, two letters, or three letters just isn’t enough,” said Michael Cohen, president emeritus of ISMP, a nonprofit that collects error reports directly from healthcare professionals.
“For example, [if you type] MEET. Is it metronidazole? Or metformin? Cohen added. “One is an antibiotic. The other is a medicine for diabetes. It’s a pretty big confusion. But when you see MET on the screen, it’s easy to select the wrong drug.”
A five-letter solution: make it stick
Omnicell added five-letter search with a software update in 2020. But customers have to register for the feature, so it’s likely unused in many hospitals. BD, which makes the Pyxis cabinets, said it intends to standardize five-letter searches on Pyxis machines through a software update later this year – more than 2.5 years after announcing for the first time to security advocates that the upgrade was imminent.
This update will be felt in thousands of hospitals: it will be much more difficult to remove the wrong medicine from the Pyxis cabinets, but also a little more difficult to remove the correct one. Nurses will have to spell confusing drug names correctly, sometimes in chaotic medical emergencies.
Robert Wells, an ER nurse from Detroit, said the hospital system he works in activated protection on its Omnicell cabinets about a year ago and now requires at least five letters. Wells struggled to spell some drug names at first, but that challenge fades over time. “For me, it’s become more complicated to withdraw from drugs, but I understand why they went there,” Wells said. “It seems inherently safer.”
Computerized medication cabinets, also known as automated dispensing cabinets, are how nearly every US hospital manages, tracks, and dispenses dozens to hundreds of medications. Pyxis and Omnicell represent nearly the entire cabinet industry, so once the Pyxis update rolls out later this year, a five-letter search feature should be within reach of most hospitals nationwide. The feature may not be available on older cabinets that are not compatible with newer software or if hospitals do not regularly update their cabinet software.
Hospital medicine cabinets are primarily accessible to nurses, who can search them in two ways. One is by patient name, at which point the practice presents a menu of prescriptions available to fill or refill. In more urgent situations, nurses can search cabinets for a specific drug, even if a prescription has not yet been filed. With each additional letter typed into the search bar, the practice refines the search results, reducing the risk of the user selecting the wrong drug.
The seven drug mixes identified by KHN, each of which involved hospital staff members who pulled out the wrong drug after typing three letters or less, were confidentially reported by frontline healthcare workers to ISMP , which has outsourced error reporting since the 1990s.
Cohen allowed KHN to review the error reports after redacting information identifying the hospitals involved. These reports revealed mixtures of anesthetics, antibiotics, blood pressure medications, hormones, muscle relaxants and a drug used to reverse the effects of sedatives.
In a 2019 mix-up, a patient had to be treated for bleeding after being given ketorolac, a painkiller that can cause blood thinners and intestinal bleeding, instead of ketamine, a drug used in anesthesia. A nurse pulled the wrong medicine from a cabinet after typing just three letters. The error would not have occurred if she had been forced to search with four.
In another mistake, reported just weeks after Vaught’s arrest, a hospital worker mixed the same drugs as Vaught – Versed, a sedative, and vecuronium, a dangerous paralytic.
Cohen said ISMP research suggests the five-letter requirement will almost entirely eliminate such errors because few cabinets contain two or more drugs with the same first five letters.
Erin Sparnon, medical device failure expert at ECRI, a non-profit organization focused on improving healthcare, said that although many medication errors in hospitals are not related to drugs, a five-letter search would result in an “exponential increase in security” when removing drugs from cabinets.
“The goal is to add as many layers of security as possible,” Sparnon said. “I’ve seen it called the Swiss cheese model: you line up enough pieces of cheese and eventually you can’t see a hole through it.”
And the five-letter search, she said, “is a damn good piece of cheese.”
At trial, prosecutors argued that Vaught made numerous mistakes and overlooked obvious warning signs when administering vecuronium instead of Versed. But Vaught’s first fundamental mistake, which made all other mistakes possible, was inadvertently removing vecuronium from a cabinet after just typing VE. If the practice had demanded three letters, Vaught probably wouldn’t have issued the wrong drug.
“At the end of the day, I can’t change what happened,” Vaught said, describing the confusion to investigators in a taped interview that aired during his trial. “The best I can hope for is that something will come of it, so a mistake like that can’t be made again.”
BD raised the default value for Pyxis cabinets to a minimum of three letters in 2019 and intends to increase it to five in an expected software update “by the end of the summer”, said the spokesperson Trey Hollern. Cabinet owners will be able to disable this feature because it is “ultimately up to the health system to configure the security settings,” Hollern said.
Perilous typos: MORFINE
At least some hospitals must have enabled the Omnicell security feature as they began alerting the ISMP to workflow issues – misspellings or typos – compounded by the requirement for more letters. Omnicell declined to comment for this story.
Ballad Health, a chain of 21 hospitals in Tennessee and Virginia, enabled five-letter search when installing new Omnicell cabinets this year.
CEO Alan Levine said it was easy to turn on the security feature after the Vaught affair, but the transition laid bare an unflattering truth: Many people, even highly trained professionals, are bad spellings. “We have people trying to spell morphine as MORFINE,” Levine said.
Ballad Health officials said one of the most common problems occurs in emergency rooms and operating rooms where patients need tranexamic acid, a drug used to help blood clot. So many nurses were delayed in surgeries by misspelling the drug by adding an S or Z that Ballad posted reminders of the correct spelling.
Even so, Levine said Ballad would not disable five-letter search. Due to the pandemic and widespread staffing shortages, nurses are “stretched” and more likely to make a mistake, so functionality is needed more than ever, he said.
“I think, given what happened to the Vanderbilt nurse, a lot of [nurses] have a better appreciation of why we do it,” Levine said. “Because we are trying to protect them because we are the patient.
Some nurses remain skeptical.
Michelle Lehner, a nurse at a suburban Atlanta hospital who activated the five-letter search last year, said she believes hospitals would be better served by isolating dangerous drugs like vecuronium, instead of complicate the search for all other drugs. The five-letter search, while well-intentioned, could slow nurses down so much that it causes more harm than good, she said.
As an example, Lehner said that about three months ago she picked up an anti-inflammatory drug, Solu-Medrol, from a cabinet with the security device. Lehner typed in the first five letters of the drug’s name but couldn’t find it. She searched for the generic name, methylprednisolone, but still couldn’t find it. She called the hospital pharmacy for help, but couldn’t find the medicine either, she said.
After nearly 20 minutes, Lehner abandoned the dispensing cabinet and pulled the medicine from an unpowered “old-fashioned” medicine cart that the hospital normally reserves in the event of a power outage.
Then she realized her mistake: she forgot the hyphen.
“If this had been a situation where we needed to administer the drug urgently,” Lehner said, “that would have been unacceptable.”
KHN (Kaiser Health News) is a national newsroom that produces in-depth journalism on health issues. Along with policy analysis and polls, KHN is one of the three main operating programs of the KFF (Kaiser Family Foundation). KFF is an endowed non-profit organization providing information on health issues to the nation.