Vanderbilt is having a rough patch. First the lethal Vecuronium error and now a "never event".
A woman at Vanderbilt undergoing kidney surgery suffered a wrong-site surgery to her kidney- a "never event". She filed a 25 million dollar lawsuit due to extensive damage and is now dependent on dialysis. Neither here nor there, but one news report said the woman was a certified nursing assistant (CNA).
In the first case, the RN was arrested and charged with reckless homicide. Should the surgeon likewise be arrested and face charges?
Hitting the first thing on the list after typing a couple letter is well recognized habit that occurs with the use of ADCs, which isn't a conscious choice, that's what a habit is. Your brain gets repetitive feedback that most often after typing a couple of letters the intended drug is at the top of list. It's a common enough issue that at a couple of places I've worked they've blocked the predictive text until at least 4 characters have been typed in. At one we even added 'dummie' results that would show up a the top of the list that would then remind the nurse to carefully read the results before picking one.
And yes, I use a pyxis daily.
That's why we have the Five Rights of safe medication administration (and other medication safety checks). As prudent nurses we don't rely only on automated tools; we use our critical thinking to ensure we are administering medications safely.
Hitting the first thing on the list after typing a couple letter is well recognized habit that occurs with the use of ADCs, which isn't a conscious choice, that's what a habit is. Your brain gets repetitive feedback that most often after typing a couple of letters the intended drug is at the top of list. It's a common enough issue that at a couple of places I've worked they've blocked the predictive text until at least 4 characters have been typed in. At one we even added 'dummie' results that would show up a the top of the list that would then remind the nurse to carefully read the results before picking one.
And yes, I use a pyxis daily.
So you habitually push IV meds without looking at what the medicine actually is? Good to know. Can I ask what hospital you work at so I can crawl to the next county on a gravel road, if need be, to get away from it?
So you habitually push IV meds without looking at what the medicine actually is? Good to know. Can I ask what hospital you work at so I can crawl to the next county on a gravel road, if need be, to get away from it?
Wow - that's quite a jump from the post you were replying to! ?
The particular assertion (of yours) that was being refuted was that typing two letters and hitting the first thing that comes up was reckless. Typing two letters and tapping the name of the medication that populates the top of the screen historically has produced the wanted/correct result quite reliably, as we have discussed many times in these threads now. That's why it's at risk of becoming a rote behavior. There is much that can be said about this case (which has mostly been said already), but to me this pyxis portion strikes me as utterly rote behavior. And there's really only one way things become rote.
Wait! The RN was arrested but no one else on the team? Even the surgeon who actually did this? At the end of the day it’s there pt, they are the one doing the surgery, it’s there responsibility.
Pinning this all on one RN is horrific.
EXACTLY! Yes she was arrested! No punishment has come for the hospital or the Doc who lies on the death certificate or lied to the ME or the Risk Mgmt sept who didn’t report the event as required by law... on and on...
Susie2310
2,121 Posts
That's why we have the Five Rights of safe medication administration (and other medication safety checks). As prudent nurses we don't rely only on automated tools; we use our critical thinking to ensure we are administering medications safely.