When Technology Creates Barriers to Care Delivery, Bad Things Happen

“Overriding was something we did as part of our practice every day. You couldn’t get a bag of fluids for a patient without using an override function.”

RaDonda Vaught, Former Nurse, Vanderbilt University Medical Center
Image Credit: Shutterstock.com

This week I came across a sobering article in Kaiser Health News (KHN) about the case of RaDonda Vaught, a former nurse at Vanderbilt University Medical Center, who is charged with reckless homicide after a medication error killed a patient. Prosecutors do not allege in their court filings that Vaught intended to hurt the patient or was impaired by any substance when she made a mistake. Hence, her prosecution is a rare example of a health care worker facing years in prison for a medical error. Vaught’s case looms large for a profession terrified of the criminalization of such mistakes — primarily because her case hinges on an automated system for dispensing drugs that many nurses use every day.

Vaught’s trial will be followed by nurses nationwide, many of whom worry a conviction may set a precedent even as the coronavirus pandemic leaves countless nurses exhausted, demoralized, and likely more prone to error. Vaught’s defense will center around her statement above, that at the time of the death, the medical center 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. Others in the profession support that statement. Michael Cohen, president emeritus of the Institute for Safe Medication Practices, and Lorie Brown, past president of the American Association of Nurse Attorneys, said it is common for nurses to use an override to obtain medications in a hospital.

Update – March 25, 2022A jury on Friday convicted former Nashville nurse RaDonda Vaught of criminally negligent homicide and abuse of an impaired adult after a medication error contributed to the death of a patient in 2017.The jury deliberated for approximately four hours in a trial closely watched by nurses and medical professionals from across the country, many worried Vaught’s case could set a precedent for medical errors leading to criminal charges.

Maureen Shawn Kennedy, the editor-in-chief emerita of the American Journal of Nursing, wrote in 2019 that Vaught’s case was “every nurse’s nightmare.”

“We know that the more patients a nurse has, the more room there is for errors. We know that when nurses work longer shifts, there is more room for errors. So I think nurses get very concerned because they know this could be them.”

Maureen Shawn Kennedy, editor-in-chief emerita of the American Journal of Nursing,

In my work, I’ve had dozens of conversations with frontline nursing staff who have complained that automated drug cabinets (ADCs) create barriers to care delivery. Whether used as a full decentralized drug distribution model or for limited distribution of controlled substances, PRN (as needed) medications, and first doses only, ADCs today are often interfaced with electronic health record systems in both large and small healthcare settings. Machine-readable (barcode) scanning is usually available to verify the drug and dose in the pharmacy before distribution, upon ADC stocking, and at the bedside before administration. Label printers have been added to the current generation of ADCs to support safe practices after medication removal.

ECRI’s Institute for Safe Medication Practices has identified three unsafe scenarios: overuse of overrides, removal of a drug from an ADC without an order, and removal of an ordered medicine from a non-profiled ADC. Healthcare practitioners have used the term “override” loosely when referring to these circumstances, perhaps because each involves the removal of medication from an ADC without a pharmacist’s review of the order. One of the best resources I’ve found on the use of ADCs is their Guidelines for the Safe Use of Automated Dispensing Cabinets.

The Tennessee case is the most recent and visible example of how technology can create barriers to effective care delivery. ADCs aren’t the only culprit here. Ask any frontline provider about EHRs and the amount of additional work they generally create. I won’t even go into the problem with “copy and paste” issues in using the EHR to document a patient visit – something that I’ve experienced myself when reviewing my own health records in My Chart.

So, how do we approach the issue of technological barriers to effective care delivery? Here are some suggestions from multiple conversations with health care leaders around the country:

Understand that frontline caregivers WILL find and create workarounds for any technological barriers they encounter. The “override” issue in ADCs is a classic example of this. “Copy and Paste” in EHRs is another. It’s basic human nature. “Put something in the way of my doing my job, and I’ll figure out a way to get around it.” Have those conversations with the team regularly. Sit them down with the vendors so they can hear firsthand what’s creating problems for the staff so they can address them in future improvements to the system.

Don’t stop with frontline staff. Bring patients into the conversation as well. If your team has issues with technological barriers, imagine what your patients are experiencing. Engage with your Patient and Family Advisory Board if you have one. If you don’t, create one. They’re the best source of information on what works and what doesn’t. Patients want to see good business practices in healthcare: good customer service, good technology, and good working relationships. They can see and compare the customer service in other industries and help healthcare get better at it.

When technology is involved, always have a “plan B.” This includes providing additional training for frontline caregivers in the effective use of the technology. Schedule regular listening sessions to allow for discussion on new challenges the staff is facing when using technology in their daily work.

Select your vendor partners carefully. Communication is vital for vendor management, so treat them as a member of your team and communicate with them accordingly. Set clear expectations of the type of support you need. Make sure you understand the amount and type of training that your frontline staff will receive when implementing new technologies. And, make sure that additional training is provided after major updates to the system or when connecting it to other systems.

Technology is a crucial ingredient of health care. Indeed, all health care consists of either human interaction, the application of technology, or, most commonly, both. Consideration of technology is vital in examining the organization and functioning of health care services and systems for many reasons. Technology is a significant component of current health care costs and perhaps the key driver of future costs. Major regulatory frameworks and institutions exist solely to manage the introduction and use of safe, effective, and efficient healthcare technology. With any implementation or use of healthcare technology, patient safety and quality must always remain the primary focus. Technology should support human interaction in care delivery. Technologies that make work more difficult for caregivers creates an environment where errors will increase with catastrophic consequences for both patients and providers. Identifying those problem technologies must occur at the frontlines at the point of care.

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