(Note: the following is a pretty long quote, but the website says specifically that this article can be republished for free.)
As the trial begins, the Nashville DA’s prosecutors will argue that Vaught’s error was anything but a common mistake any nurse could make. Prosecutors will say she ignored a cascade of warnings that led to the deadly error.
The case hinges on the nurse’s use of an electronic medication cabinet, a computerized device that dispenses a range of drugs. According to documents filed in the case, Vaught initially tried to withdraw Versed from a cabinet by typing “VE” into its search function without realizing she should have been looking for its generic name, midazolam. When the cabinet did not produce Versed, Vaught triggered an “override” that unlocked a much larger swath of medications, then searched for “VE” again. This time, the cabinet offered vecuronium.
Vaught then overlooked or bypassed at least five warnings or pop-ups saying she was withdrawing a paralyzing medication, documents state. She also did not recognize that Versed is a liquid but vecuronium is a powder that must be mixed into liquid, documents state.
Finally, just before injecting the vecuronium, Vaught stuck a syringe into the vial, which would have required her to “look directly” at a bottle cap that read “Warning: Paralyzing Agent,” the DA’s documents state.
The DA’s office points to this override as central to Vaught’s reckless homicide charge. Vaught acknowledges she performed an override on the cabinet. But she and others say overrides are a normal operating procedure used daily at hospitals.
While testifying before the nursing board last year, foreshadowing her defense in the upcoming trial, Vaught said at the time of Murphey’s death that Vanderbilt was instructing nurses to use overrides to overcome cabinet delays and constant technical problems caused by an ongoing overhaul of the hospital’s electronic health records system.
Murphey’s care alone required at least 20 cabinet overrides in just three days, Vaught said.
“Overriding was something we did as part of our practice every day,” Vaught said. “You couldn’t get a bag of fluids for a patient without using an override function.”
Overrides are common outside of Vanderbilt too, according to experts following Vaught’s case.
Michael Cohen, president emeritus of the Institute for Safe Medication Practices, and Lorie Brown, past president of the American Association of Nurse Attorneys, each said it is common for nurses to use an override to obtain medication in a hospital.
Basically it looks to me that from a technical standpoint, this nurse ignored numerous safeguards, but that as a practical matter, the consensus of actual nurses seems to be that these safeguards are routinely ignored, and this error could indeed happen to anyone.
I feel this is a broader problem, in that safeguards are instituted which are not practical and will be routinely ignored. Another example is disclaimers on financial and legal documents. I was once closing on a mortgage and signing paper after paper that the closer passed over (I knew the general idea of what each was, but didn’t actually read any of them) and I asked the closer if in her history of closing mortgages anyone had ever actually read each paper. She said only one time, an earnest young couple closing on their first ever mortgage. Point being that these documents might have been written up with the intention of having people know the information in them but as a practical matter, reading each paper is not practical and simply won’t be done.
I think this nurse ignoring the various pop-up warnings falls into the same category. Yes, in theory you should read all these pop-up warnings but there are so many of them and you don’t have all day for this procedure, so you get into the habit of ignoring them.
The same goes for various safety measures. You can get people to do some measures if they’re simple and effective, but once they get too cumbersome then people will just disregard them for the most part. (I’ve seen a lot of professionals on construction sites, and in general they absolutely do not conform to the safety measures recommended for their various power tools and the like.)
I think a big part (though not the entirety) of it is considering each item individually. If you were thinking of a mortgage closing with no disclosures at all, and now you were thinking of mandating one disclosure for one important matter, that might make sense. It might be reasonable that people will read one paper. But meanwhile, another well-meaning regulator is mandating a disclosure on another matter, and that lessens the likelihood that either will be read. And so on; by the time you get to 25 disclosures, there’s virtually no likelihood of anyone reading anything.
In sum, the broader point is that you need to consider the practical impact of various precautionary measures, not just in terms of how much you’re imposing on people you’re subjecting to them but also in terms of much they make it less likely that people will conform to these measures altogether. The more specific point is that sometimes each individual measure makes sense from a cost/practical consideration standpoint, but the cumulative effect of numerous such measures undermines all of them.
