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This was a tragic case of how an overworked nurse accidentally killed a patient by administering the wrong medication with a similar name. The HN angle is that part of the error resulted from user experience design choices in the hospital's electronic medication cabinet.

An overwhelming number of alerts were routinely displayed, leading to a form of banner blindness and frequent overrides. An overzealous autocomplete suggested the wrong drug with the same first two letters. There was apparently not a permission system in place that blocked her from administering the drug for this patient.

The patient died soon after administration, and the nurse is now facing criminal prosecution for reckless homicide. Other nurses across the country are concerned, especially given their overwhelming workloads during and after covid and the frequent room for error.

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Overrides should never be common and whoever overlooked that was negligent in allowing the situation to get that way - and the responsibility extends to manufacturer and whoever is the vendor managing the EMR system. Blocks exist for a reason and overriding them should never be common procedure.

A fire alarm that triggers every day for no reason is useless. In weeks people will ignore it and, when a fire actually happens, they'll die.

At the end of the day you had a nurse administer a deadly medication that had a huge warning printed on the lid administer to a patient that didn't need it. There is a lot of systemic culpability there, patient safety at Vanderbilt is an afterthought, but that should not mean that there is no individual culpability.

Yep. According to the article she accepted the blame and acknowledged her mistake.

But there were also a bunch of systematic factors contributing to the error. The UX stuff was actually buried very deep in the article, I just thought it was an interesting part of healthcare that's rarely discussed.

The medication she administered was in a different form, even (powder instead of liquid, like kool-aid). But that still didn't stop the mistake.

Everyone in healthcare right now is exhausted all the time, understaffed and overworked, and enough small errors can accumulate into major catastrophes. Didn't seem like there was a process in place to prevent this, either in software or training or day to day.

She's not trying to avoid responsibility, but also, should she get prison time for a mistake vs losing her license and job? And who else in the chain of command should be held responsible? How will this ripple across the healthcare industry?

We have a hard time filling nursing positions already, and the other nurses interviewed for the article all worried the same could've happened to them.

I'm teaching a nursing chemistry course right now. There's a certain kind of character who sees the course not as an opportunity to learn but as an obstacle to overcome on their way to make a living. We are trying our damnedest best to weed those out.

What has happened is this: nurse tasked to administer Versed. Versed - what's that, don't care. <goes to medicine cabinet> VE-clickedy-click. Vecuronium? Dunno what's that, but it's good enough. Big warning! Medicine be dangerous! Medicine is administered, patient dies. Nurse says, mistakes were made, but Jesus loves me!

Enough of that.

> There's a certain kind of character who sees the course not as an opportunity to learn but as an obstacle to overcome on their way to make a living.

You might be surprised to hear that most people you know are doing what they can to make a living.

It seems like you may not see it that way, while instead making a moral judgement of who “really cares”. I understand your sentiment, but I would advise caution in such situations.

You can want to make a living, but also have a personality where you care why, and how things work. Where you are fascinated with the universe, and seek to know more.

Some jobs are simply not for those whose personailty does not mesh.

Another example would be an introvert, taking a job as an MC. Not the best fit there.

I understand your viewpoint, but even as an engineer who thinks that I care about figuring things out - oftentimes I don’t as well. It’s all really dependent on my personal/mental well-being or even systemic situation/pressures. My point being that such traits are a spectrum and can vary over time.

And you feel this way when someone could die if you get it wrong?

GP is not talking about the nurse which got it wrong, by accident, but about those that clearly are going to have difficulty doing the job properly. There's more to a job than cramming info.

Are you trying to tell me, if you were a teacher, and you were to pass or fail a student who you knew would end up unable to perform, you'd just say "Oh well, hope they get better!", and pass them?

I'm not sure what you're trying to argue here. I think you've misread the GP's statement.

> exhausted all the time, understaffed and overworked

That's precisely what they want, they want to be understaffed and underworked to create the myth of the suffering heroic doctor, so that they can justify all the other privileges they get and the gigantic salaries, bribes from multi-level marketing, and disgusting hedonistic trips to the Caribbean.

There's good doctors too and guess what? They're hated by mainstream doctors. I love those guys, they're so good.

If doctors were actually good the absolute first thing they would instantly do is allow there to be ten times as many doctors, that would make everyone in America much healthier instantly.

These guys are like Google, but a pentillion times more expensive. In fact one time I went in, I started talking to the doctor, he just started googling right in front of me.

Not sure at all what you are talking about. This is about a nurse, not a doctor. The difference between the two (especially in pay) is vast, nurse != Doctor Jr.

Nurse practitioner yes, pretty much a doctor. Better actually, means less prestigious, which means better.

What do you mean if doctors were good they would allow ten times as many people to become doctors?

That's not how it works. The process of becoming a doctor is much more formalised than you seem to insinuate and mostly does not depend on a single individual or a group of individuals other than indirectly.

I do agree that some doctors have a Messiah complex and are self-important to the point of absurdity, but they still mostly tend to do a good job.

I would argue that the limiting factor of why there is a general shortage of doctors and nurses is that the job is not the easiest one, physically or mentally, people tend to work long hours and awkward shifts and the education itself is challenging and long.

> tend to work long hours and awkward shifts and the education itself is challenging and long.

Both of those are professional masochism. In particular older doctors make sure would-be doctors and young doctors go through decades of shit in order to keep the old doctor's privileges and salaries incredibly high, without making it obvious it is a completely cornered market. If doctors could, they would close the medical schools. But they know they would get lynched by a mob, for real, really in real life, the laws against it would stop nothing, so they have no choice but to leave medical schools open producing a symbolic number of replacements with an excrutiating amount of hazing and harmful education, which very much makes them worse doctors. And lots and lots of attrition, the old doctors love that, mmm attrition, all the benefits of saying there's slots in medical schools without the actual competition from petulant young doctors.

> If doctors were actually good the absolute first thing they would instantly do is allow there to be ten times as many doctors

They also want every doctor to be minimally competent and that goes completely against the goal of having as many doctors as possible, or, better, highlight the fact that this is how many doctors (or healthcare professionals) we can have considering cost of education, both monetary and in time.

If you really want more doctors, you could also pay software engineers and lawyers less. I was married to a doctor and I know how much she studied to be one. It's much easier to become an average software engineer or lawyer than becoming an average doctor. And you wouldn't want to meet an average doctor right after totalling your car with you inside. Changing the financial returns would make the profession more attractive to those who are in the game for money.

If I could make what I make counting squirrels in my backyard, do you think I'd think twice before leaving software engineering? ;-)

Was mostly talking about nurses and other hospital staff, not the doctors. Sorry for being unclear.

Yeah, exactly. How did it get this bad? It can't just be this one nurse ignoring warnings. Reminds me of UAC on Windows, but with deadly consequences.

Unfortunately, UAC conditioned a whole lot of people to just click OK without reading (or understanding) the message.

Cookie prompts are probably doing the same too

After basic cardiovascular death and cancer death, the next most common is "medical errors" such as this.

that's not how I read the article. This nurse made a huge error and repeatedly overrode clear alert systems. The only complaint I can see is needing to type the formal name of the drug instead of the brand name.

That part of the article makes me wonder how often they are asked to override alerts. Is it something that they have to do for every medication? For commonly prescribed medications?

It's possible the particular medication management system has it as an option of some sort-only some meds can be overriden, only some users can override, or maybe some manager can turn off completely the ability to override. There's definitely a time and a place for overriding meds, and nothing in this story indicates that particular workflow is too prevalent or pervasive.

It's possible, we just don't know. The prosecution doesn't seem to be saying. Really, my point is (by example) if regular medications require 4 confirmations or overrides and this one requires 5, that's a problem.

> There was apparently not a permission system in place that blocked her from administering the drug for this patient.

Why should there be? Versed is a Schedule IV drug, vecuronium is not scheduled-if anything, the system worked since she was able to dispense a drug that wasn't controlled as well as the drug she had permission to dispense.

In the acute care space there's lots of instances where an end user will need to override something for some reason or another. It's ultimately the end user's fault for neglecting the errors.

> Why should there be? Versed is a Schedule IV drug, vecuronium is not scheduled-if anything

DEA scheduling is supposedly about abuse potential, not safety. Vecuronium is one of the most dangerous drugs in the hospital. It's used to paralyze essentially every muscle in the body except the heart to keep a patient from moving during surgery or to get a breathing tube through spasming vocal cords. These muscles include the ones used for breathing. Most physicians aren't allowed to give it. Those that are have trained for years before they're allowed to give it independently.

There are no circumstances when a nurse should be giving this drug without a physician closely supervising.

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