Five Letter Fix: Pinning
Omnicell added a five-letter search with a software update in 2020. But customers must subscribe to this feature, so many hospitals probably don’t use it. BD, which makes Pyxis cabinets, said it intends to make five-letter searches standard on Pyxis machines through a software update later this year — more than 2.5 years after it first told security advocates about the upcoming update.
This upgrade will be felt in thousands of hospitals: it will be a lot harder to get the wrong drug out of Pyxis cabinets, but it will also be a little harder to get the right one. Nurses will need to correctly pronounce confusing drug names, sometimes in chaotic medical emergencies.
Robert Wells, a Detroit emergency room nurse, said the hospital system he works for activated security on their Omnicell cabinets about a year ago and now requires at least five letters. At first, Wells found it difficult to write the names of some of the drugs, but over time this problem disappeared. “It has become much more difficult for me to get the drugs out, but I understand why they went there,” Wells said. “It seems safer.”
Computerized medication cabinets, also known as automatic drug dispensers, are how nearly every hospital in the US manages, tracks, and dispenses dozens to hundreds of medications. Pyxis and Omnicell account for almost the entire cabinet industry, so once the Pyxis update is released later this year, the five-letter search feature should be available to most hospitals in the country. This feature may not be available on older hospitals that are not compatible with the new software, or if hospitals do not update their hospital software regularly.
Hospital medicine cabinets are mostly accessed by nurses who can search them in two ways. One for the patient’s name, after which the cabinet presents a menu of available prescriptions that need to be filled or updated. In more urgent situations, nurses can look in the rooms for a certain medicine, even if the prescription has not yet been written. With each additional letter entered in the search string, the cabinet refines the search results, reducing the likelihood that the user will select the wrong drug.
Frontline health workers have confidentially reported seven cases of drug confusion identified by KHN, all of which involved hospital staff seizing the wrong drug after typing three or fewer letters.
Cohen allowed KHN to review the bug reports after editing information that identified the hospitals involved. These reports revealed a mixture of anesthetics, antibiotics, blood pressure medications, hormones, muscle relaxants, and a drug used to reverse the effects of sedatives.
In a 2019 confusion, a patient had to be treated for bleeding after being given ketorolac, a pain reliever that can cause blood thinning and intestinal bleeding, instead of ketamine, a drug used for anesthesia. The nurse took out the wrong medicine from the cupboard by typing only three letters. The mistake would not have happened if she had to search with four.
Another mistake, reported just weeks after Vought’s arrest, was that a hospital employee had mixed up the same drugs Vought was taking, the sedative Versed and the dangerous paralytic vecuronium.
Cohen said the ISMP study suggests that requiring five letters would almost completely eliminate such errors because few cabinets contain two or more drugs with the same first five letters.
Erin Sparnon, medical device malfunction expert at ECRI, a non-profit organization dedicated to improving healthcare, said that while many hospital drug errors are not related to drug cabinets, a five-letter search will result in “an exponential increase in safety” in drug retrieval. from cabinets.
“The goal is to add as many layers of security as possible,” Sparnon said. “I’ve seen this called the Swiss cheese model: you line up enough pieces of cheese and in the end you don’t see a hole in them.”
And a five-letter search, in her words, “a damn good piece of cheese.”
Here, a former nurse at Vanderbilt University Medical Center in Nashville, was arrested in 2019 and found guilty of felony homicide and gross neglect of a disabled person during a controversial trial in March. She can serve up to eight years in prison. Her May 13 sentencing is expected to draw hundreds of protesters who believe her medical malpractice should not have been prosecuted as a crime.
At trial, prosecutors argued that Voight had made many mistakes and overlooked obvious warning signs by administering vecuronium instead of Verced. But Vought’s first and fundamental mistake, which made all other mistakes possible, was unintentionally removing vecuronium from the cupboard after he had printed only VE. If the cabinet had demanded three letters, Voight probably wouldn’t have pulled the wrong drug.
“Ultimately, I can’t change what happened,” Voight said, describing the confusion to investigators in a taped interview that was shown at her trial. “The best I can hope for is that something will come of it and that mistake like this won’t happen again.”
After details of the Vought case became public, Cohen said, the ISMP resumed its calls for safer searches and then made “several calls” with BD and Omnicell. ISMP said that during the year, both companies confirmed plans to customize their cabinets based on its guidance.
In 2019, BD raised the standard for Pyxis cabinets to a minimum of three letters and intends to raise it to five in a software update expected “by the end of the summer,” spokesman Trey Hollern said. Closet owners will be able to disable this feature because “ultimately the healthcare system has to tweak the security settings,” Hollern said.
Omnicell added a “recommended” five-letter search via a 2020 software update, but left that feature deactivated, so its cabinets allow single-letter searches by default, according to the company’s press release.
Dangerous typos: MORPINE
At least some hospitals must have activated the Omnicell security feature because they started alerting the ISMP to workflow issues — misspellings or typos — that were exacerbated by the need for more letters. Omnicell declined to comment on this story.
Ballad Health, a network of 21 hospitals in Tennessee and Virginia, has activated a five-letter search when installing new Omnicell cabinets this year.
CEO Alan Levin said it was easy to enable the security feature after the Vaught case, but the transition exposed an unflattering truth: Many people, even highly trained professionals, write poorly. “We have people trying to pronounce morphine like MORPINE,” Levin said.
One of the most common problems occurs in emergency rooms and operating rooms, where patients require tranexamic acid, a drug used to increase blood clotting, Ballad Health said. So many nurses got stuck in their offices for mis-spelling medicine by adding an S or Z that Ballad posted reminders of the correct spelling.
Despite this, Levine said that Ballad would not turn off five-letter search. Due to the pandemic and widespread shortages, nurses are “stressed” and more likely to make a mistake, he said, so the feature is needed more than ever.
“I think, given what happened to the nurse at Vanderbilt, a lot [nurses] better understand why we are doing this,” Levin said. “Because we’re trying to protect them because we’re patients.”
Some nurses remain unconvinced.
Michelle Lehner, a suburban Atlanta hospital nurse who activated a five-letter search last year, said she thinks hospitals will be better served by isolating dangerous drugs like vecuronium instead of making it harder to find all other drugs. A five-letter search, though well-intentioned, can slow nurses down so much that it does more harm than good, she says.
As an example, Lehner said that about three months ago, she went to get the anti-inflammatory drug Solu-Medrol from a safety cabinet. Lehner typed in the first five letters of the drug’s name, but could not find it. She looked for the generic name, methylprednisolone, but couldn’t find it. She called the hospital pharmacy for help, but they couldn’t find a cure.
Nearly 20 minutes later, Lehner left the dispenser and pulled medicine from a non-functioning “old school” medicine cart that the hospital usually reserves in case of a power outage.
Then she realized her mistake: she forgot the hyphen.
“If this was a situation where we needed to be given medication on an emergency basis,” Lehner said, “that would be unacceptable.”