A Word of Caution in Overriding at the Electronic Drug Dispensing Cabinet

In December 2017, a nurse in a prestigious academic medical center used the “override” function in an electronic medication dispensing cabinet to get a medication to sedate a patient who was anxious about going into an MRI scanner. The nurse had been sent to the radiology suite to quickly administer a medication to calm the patient and get the study done. The nurse used “override” because the nurse did not find the medication on the patient’s profile. The nurse typed “Ve” into the search function and removed vecuronium, a paralyzing agent, from the cabinet and gave it to the patient. It was only later when the patient’s condition deteriorated in the scanner and the patient subsequently died that it was learned that vecuronium had been administered when the nurse had intended to give Versed, the trade name for midazolam, a sedative.

This is obviously a very sad case, but it was made even worse in January of this year when the nurse was indicted for murder. Following the notion of the Just Culture, punishing the nurse for this error would only be justified if his/her action was intentional or if there had been a reckless disregard for the standard procedures that other nurses in the same situation would have followed. Assuming there was no malicious intent, imagine how the nurse feels. He or she is clearly a second victim.

I don’t know all of the facts of the case, but none of the news reports suggest the nurse was trying to harm the patient. They all suggest that the nurse did not realize she had taken the wrong drug. I don’t know if another nurse in that particular hospital would have used the override in that situation, but I am concerned that in many hospitals, it would have been. Why do I believe this? Because all too often, we are concerned about speed and efficiency and we give our people the message that they need to move quickly to get the job done. We do not spend enough time coaching staff about our safety systems and making it clear with both our words and actions that safety is more important than speed. 

In the typical hospital case, there are 4 steps in the process to administer a medication to a patient (by the way, neither in my medical school education, nor during my pediatrics residency did anyone fully explain this sequence to me and the importance of all the steps). First, the licensed physician or advanced practitioner orders the medication. Next, the pharmacist checks the patient’s record for allergies and incompatibilities, as well as the dose and route of administration. He or she then verifies the order. Next, the pharmacy dispenses the medication. The drug dispensing cabinetry saves time because the drug does not need to be transported from a central location. The act of verifying the order in the computer tells the machine what to dispense. The nurse then does a final check that the patient, drug, dose, route, and time are correct and administers the drug to the patient. The drug dispensing cabinet has an override function because the manufacturer wants to allow the medication to be removed and administered quickly, if necessary, before ordering and verifying have been done.

In a true clinical emergency, time is of the essence. Think of a patient coming into the ED in full cardiac arrest. In this case, the provider running the code is giving verbal orders and other team members are getting the drugs (generally from a code cart) and administering them without the verification step. But what do you think about the case of the anxious patient? Is this truly an emergency? It is easy to see retrospectively that if the nurse had not used the override or if it was not even an option, and instead the nurse had waited for an order for Versed and its verification, this tragedy would not have happened.

At GBMC, we have some emergency medications in some drug dispensing cabinets, and therefore, we do not want to eliminate the ability to override. However, we do want to eliminate non-emergency overrides.

Our pharmacy leaders study the use of the override function at GBMC. Vaishali Khushalani, PharmD, GBMC’s Medication Safety Officer, has shared with me the insight gained by our daily medication override reviews. Most overrides that are occurring before a provider has entered the order are not for emergency medications; rather they are for acetaminophen (Tylenol), amoxicillin, and ibuprofen (Advil). In addition, there are many overrides within a minute or two of the order being entered. This does not give the pharmacist enough time to review and verify the order. The provider can order a medication “STAT” and the administering nurse can ask for a drug as “high priority.” In the month of April, there were 3,609 STAT/high priority orders and the average time to verify high priority/STAT medications was 6 minutes. There were 78,415 total medication orders in April and the average time to verify all medications was 12 minutes. While I am sure the mean performance includes some outliers, I believe that these are reasonable times to wait for the extra protection of the pharmacist verification step.

Vaishali and her colleagues are working closely with our nursing leaders to learn more about the reasons for the use of the override. They want to assure there are no significant delays in the verification of ordered medications so that we can eliminate non-emergency overrides. This ensures that patient needs are met without compromising patient and staff safety.

Our physicians, nurses, advanced practitioners, and pharmacists work extremely hard to get our patients what they need. We must all work together to make our system even safer than it is today. What do you think?

Way to go, Gilchrist!

Gilchrist was recently awarded the 2019 Health Care Hero Award for “Advancements and Innovation in Health Care” by The Daily Record. This award honors organizations and individuals who have played a major role in improving the quality of healthcare in Maryland. Recognized for “its professional achievements, community involvement, and inspiring change,” Gilchrist was applauded for its innovative patient care programs, which focus on meeting the needs of the seriously ill in our community. This includes home-based elder medical care for those who have difficulty physically making it to the doctor’s office.

Congratulations to all our Gilchrist colleagues for their hard work and for getting the recognition they so rightfully deserve!

Above and Beyond…

I want to extend my appreciation and gratitude to James Wilkins, a GBMC security officer, who was instrumental in helping a patient of ours reunite with his family.

Officer Wilkins was at home when he recognized a photograph from an Endangered Missing Person alert as a GBMC patient. The patient, who suffers from dementia and other medical conditions, was unfortunately separated from his family.

When James saw the alert on Facebook, he immediately notified the Aberdeen Police Department. The police positively identified the missing man, who was eventually reunited with his grateful family.

I want to THANK Officer Wilkins for his quick thinking to ensure this patient's safety and for doing his part, outside of his place of employment, to reunite this man with his family.

GBMC Employees Helping Our Community…

It’s no secret that we have some amazing GBMC employees who freely volunteer their time and do wonderful work in the community.

I was recently made aware by David Vitberg, MD, Division Chief of Medical and Surgical Critical Care Medicine, that GBMC NICU Nurse Manager, Kristin Trawinski, and Labor & Delivery Nurse Manager, Rachel Farbman, graciously volunteered their time for a very important training session with Baltimore County Fire Department's (BCFD) EMS providers. The event was attended by both career and volunteer EMS personnel.

Two BCFD paramedics presented during the training session a case of a complicated neonatal delivery. Although neonatal resuscitation is a rare call in the EMS world, EMS providers must be prepared for these low frequency, profoundly high-acuity emergency calls as the first link in the emergency medical system.

After the presentation of the case, a roundtable conversation took place between the two EMS presenters, Kristin, Rachel, and the audience. The lecture was also live-streamed to providers around the county.

The training, according to Dr. Vitberg, who is also Deputy Medical Director for Baltimore County Fire Department, was incredibly well-received by all in attendance, and as Kristin’s and Rachel’s colleague, he was extremely grateful they joined him at this event.

Thank you, Kristin and Rachel, for being stellar representatives of our Maternal Child Health Services and of GBMC!