At U.S. hospitals, a drug mix-up is just a few keystrokes away

More than four years ago, Tennessee nurse RaDonda Vaught typed two letters into a hospital’s computerized medication cabinet, selected the wrong drug from the search results, and gave a patient a fatal dose.

Vaught was prosecuted this year in an extremely rare criminal trial for a medical mistake, but the drug mix-up at the center of her case is anything but rare. Computerized cabinets have become nearly ubiquitous in modern health care, and the technological vulnerability that made Vaught’s error possible persists in many U.S. hospitals.

Since Vaught’s arrest in 2019, there have been at least seven other incidents of hospital staffers searching medication cabinets with three or fewer letters and then administering or nearly administering the wrong drug, according to a KHN review of reports provided by the Institute for Safe Medication Practices, or ISMP. Hospitals are not required to report most drug mix-ups, so the seven incidents are undoubtedly a small sampling of a much larger total.

Safety advocates say errors like these could be prevented by requiring nurses to type in at least five letters of a drug’s name when searching hospital cabinets. The two biggest cabinet companies, Omnicell and BD, agreed to update their machines in line with these recommendations, but the only safeguard that has taken effect so far is turned off by default.

“One letter, two letters, or three letters is just not enough,” said Michael Cohen, the president emeritus of ISMP, a nonprofit that collects error reports directly from medical professionals. – READ MORE