At US Hospitals, a Drug Mix-Up Is Just a Few Keystrokes Away
By Brett Kelman
Computerized medication cabinets — or automated dispensing cabinets — help U.S. hospitals keep track of hundreds of drugs efficiently, but the technology carries risk from human error. The nurses who typically access them often must search by name, with the field of possibilities narrowing with each consecutive letter entered. Most of the systems are designed to allow a search with only a few letters, which sets the user up to inadvertently choose the wrong medication. "One letter, two letters, or three letters is just not enough," declares Michael Cohen, president emeritus of the nonprofit Institute for Safe Medication Practices (ISMP), which has been gathering error reports from medical professionals since the 1990s. Typing in M-E-T, for example, would yield results including diabetes drug metformin and antibiotic metronidazole — a significant error if the wrong one is selected and administered. According to reports provided by ISMP, mix-ups in the past few years have involved staffers mistakenly pulling the paralytic vecuronium instead of the sedative Versed, the pain reliever ketorolac instead of the anesthesia drug ketamine, the diabetes treatment Pitressin instead of the labor inducer Pitocin, and the antibiotic Rocephin and overdose antidote Romazicon instead of the paralytic rocuronium. Medicine cabinet makers Omnicell and BD are updating their technology so that users get search results only after entering five-plus letters, but so far hospitals have the ability to turn these features off.
Read more on Kaiser Health News.