We often hear media reports about the dangers of medication errors, on both the patient and the “second victim” –- the clinician who accidentally and unintentionally made the harmful mistake. A recent report on 60 Minutes called attention to something we – thankfully – rarely hear about: A nurse intentionally administering lethal doses of medications to kill patients.
We often hear media reports about the dangers of medication errors, on both the patient and the “second victim” –- the clinician who accidentally and unintentionally made the harmful mistake. A recent report on 60 Minutes called attention to something we – thankfully – rarely hear about: A nurse intentionally administering lethal doses of medications to kill patients. How someone could do this is beyond comprehension.
The shocking story, which happened over the course of many years before the nurse was caught and convicted about 10 years ago, called attention to the important role medication dispensing cabinets – like the Pyxis MedStation® – play in helping to manage, secure and track medications at the point of care. In fact, the 60 Minutes segment cited the transaction logs from the Pyxis MedStation as a primary piece of evidence.
In parts of the 60 Minutes piece, an uneducated viewer may have been led to believe that it was easy for this nurse to access lethal drugs, but those of us who work in the health care industry know that modern medication dispensing is much safer and more sophisticated than in the past, when these incidents occurred.
As medication dispensing at the point of care became more ubiquitous in hospitals, more controls were added to the technology including individual username and passwords (or fingerprint recognition) to access the system, individual “CUBIES®” and compartments that only give access to the individual drug(s) prescribed to the patient. Other than in emergency situations, drugs are not available for removal until a pharmacist has reviewed the physician’s order for that patient. The scenario painted by 60 Minutes of the nurse accessing lethal medication and disguising it by telling the system he was removing Tylenol would be unlikely with proper implementation of today’s technology.
As CareFusion and hospitals gained more experience with automated dispensing cabinets, the technology continued to evolve and additional safeguards were created to help prevent unintended medication errors. This includes best practices such as storing medications that had a look-alike names or packaging in segregated, single medication containers.
Today’s technology also can restrict nurses’ access to only the medications that have legitimate physicians’ orders, and are reviewed by a pharmacist for correct dose, therapeutic application and potentially harmful interactions with other medication. When nurses’ access is limited to medications that have a physician’s order and are verified by a pharmacist, the nurse has access to only the medication ordered. No other medications can be accessed. This reduces the risk of a nurse removing an incorrect medication, either deliberately or by accident.
Finally, most hospitals have incorporated bar code scanning at the bedside of the patient’s ID and medication as a final check to ensure proper administration. All of these technologies have improved the safety of the medication process.
The Institute for Safe Medication Practices (ISMP) has also developed guidelines and a safety self-assessment for automated dispensing cabinets. These tools can help hospitals ensure they are following best practices and offer a self-assessment to determine the hospital’s individual level of safety in the use of automated dispensing cabinets.
Importantly, since this case took place, many states have adopted laws that strengthen requirements for criminal background checks and employer disclosures.
While it’s not always possible to stop an evil person who intends to harm people, modern medication dispensing technology would make it much more difficult, to harm patients intentionally through improper medication administration. As horrific as the story was on 60 Minutes, I am comforted knowing that good people have worked for their entire careers to develop the technology and best practices to create a safer and more secure system of dispensing medication in hospitals.