This is by no means the first time that an NMBA has caused a fatal error—the Institute for Safe Medication Practices (ISMP) has been reporting on them since the 1990s (sidebar). These repeated tragedies show that “directors of pharmacy have been hitting the snooze button on this for at least 25 years,” said Jeffrey Norenberg, PharmD, PhD, the director of the radiopharmaceutical sciences program in the College of Pharmacy at the University of New Mexico Health Sciences Center, in Albuquerque. “Departments of pharmacy are culpable in ignoring the mandate from the Joint Commission, which requires prospective medication order review by a pharmacist and that formulary controls are in place for all drugs used in radiology.”

ISMP President Michael R. Cohen, RPh, MS, FASHP, agreed that this latest error points to a serious, widespread safety gap. Indeed, “this is the type of thing that could happen at other hospitals,” he said in an interview.

The Vanderbilt nurse, according to the report from CMS, typed “ve” into the ADC and ended up with vecuronium rather than Versed. In the process, she also had used the machine’s override feature.

The Limits of Technology

Dr. Norenberg agreed that the Vanderbilt error underscores the limits of ADCs and other medication safety technology. As noted, the Joint Commission standard recommends that all medication orders be reviewed by a pharmacist. The ADC can provide this oversight, to a point, limiting access to certain drugs. “But if one overrides the controls in the ADC to gain access to the medications, this effectively removes all the safeguards that have been put in place,” he explained.

At the time of accessing a drug from the ADC, the standard of practice is also to check the drug name against the order. Yet the Vanderbilt nurse failed to look at the name of the drug from the vial, according to the CMS report, Dr. Norenberg pointed out.

As for why pharmacy departments often struggle to maintain adequate oversight of radiology, Dr. Norenberg offered a few possible explanations. It’s partly due, he said, to pharmacists often lacking expertise managing the drugs that are typically used in radiology. But it’s also a function of the transient nature of the patients who move through radiology. “Patients are in and out,” he said. “Communication with the referring physician and/or the hospital service area responsible for patient care is difficult, inconsistent and often incomplete.”

On balance, Dr. Norenberg added, radiology departments are actually very safe. “Millions of patients receive radiopharmaceuticals, other contrast agents and adjuvant drugs every year,” he said. “But when there are problems, they can be catastrophic,” with vecuronium being a case in point. In fact, “there’s perhaps not a more dangerous drug than vecuronium,” he stressed.

Fortunately, like other reported medication errors, lessons can be learned from the Vanderbilt tragedy, Mr. Cohen suggested. He noted, for example, that vecuronium may be best left out of ADCs in areas of the hospital where it is not immediately necessary. An anesthesiologist can always bring it up as needed, or there could be a rapid sequence intubation kit in some areas, he explained.

A barcode scanning system also can help catch this type of error before it harms a patient. But this safety tool was missing in the Vanderbilt case, which involved an overridden order and not a prefilled or pharmacy-prepared dose. “We do have barcode scanning at 95% of hospitals right at bedside. But sadly in the OR, in the ER, in radiology suites and other off-the-beaten-path areas in the hospital, barcode systems often aren’t activated yet. And that’s a problem, because you need [the scanning technology] wherever drugs are given.”

Labeling issues may play another critical role for high-risk drugs. “I’ve seen some poorly labeled neuromuscular blocker containers,” Mr. Cohen added. “You couldn’t even see that it was a paralyzing agent. That should be in red with enhanced warnings.”

Monitoring policies, too, are important for radiology or anywhere patients are left alone after getting IV drugs. “Even midazolam can cause breathing problems,” he noted. Pulse oximetry may be one useful safety measure to consider.

And there is another silver lining in the Vanderbilt tragedy: Reporting errors is key to eliminating future errors. It allows both the institution to make changes to improve patient safety, and allows other institutions to learn from their mistakes. When requested, information sent to ISMP can be privileged and protected, Mr. Cohen noted. Many of these errors are covered in ISMP publications such as its Quarterly Action Agenda.

“It’s not just about looking at errors made at your hospital. That’s important,” Mr. Cohen said. “But even more important are these deaths and serious injuries to patients that happen elsewhere; learn from them and take action before it happens at your [facility].

“We hope people read cases like this one and look at their own systems to see what holes may exist that they can plug before another incident like this can happen,” he added.

An Anniversary of Safety

ISMP is celebrating its 25th anniversary in January 2019. “I think that, as a nation, we’ve made phenomenal improvements over the last 25 to 30 years. A lot of attention has been paid to patient safety,” Mr. Cohen said. “We’ve developed and invested in new technologies, such as barcode scanning and electronic prescribing. Even automated dispensing cabinets can be used in a very safe manner with some enhancements.”

In addition to the technology, he suggested that regulation also has significantly improved. Not only have practitioners and hospitals learned from reported incidents, but the FDA also has learned valuable lessons. “Is that to say the problem is all over with? As you can see, absolutely not,” Mr. Cohen said. “It will always be out there to some extent. We have human beings working with the system.”