₦airaland Forum

If you override the system and give the wrong drug, that's on you

NotOfThisWorld:
I am so glad she is not black. She should face the consequences of her actions. RIP to the patient.

What actions exactly?

From the OP, there was a glitch in the dispensing machine so she used the override function (regularly done) so she can get the drugs.

So what actions should she face the consequences for?

Or was there another way to get the medication without using the override function?

Or are there some nuances not captured in the story that makes her more culpable?

Skydivine:
Medical error particularly medication error is not an easy and pleasant thing to happen, both to the victim and the perpetrator.
However, the standard of care as enshrined in nursing curriculum has not changed despite the use of technology. The principal and the responsibility of the nurse for medication administration is what is known as the 5 rights;
Right patient
Right drug
Right dose
Right time
Right frequency
This is the standard of practice with or without technology. Every nurse learned this at school.

Now question now is, why did she not follow this basic rule? It is easy to get caught up in technology but when the chips are down and there is a case of gross negligence, everyone will revert to the basics .
Particularly for this case, the reoccurring question would be, what would another nurse with the same qualifications and experience do in a situation of such system glitch?
Obviously, the system glitch presented a situation for increased mindfulness, absolute concentration with zero distractions in proceeding with the medication administration.
If in doubt, seek help from your supervisor.

There is a guts instinct that comes with experience. If something does not feel right , most times, it is not right. Double check! Cross check! It takes only a few minutes to do so.

We know it is always a busy schedule and heavy work load, with lots of tasks demanding your attention at the same time, but remember, your life and the patient’s life is at stack.

Hmmmmmm

From the write up ...the requested drug was not dispensed by the machine. The override was activated. What happens when the override is activated? ...is it a substitute drug is dispensed? ... recommended? Is the nurse supposed to just administer the drug? ... or ch CK with the doctor.? People in the medical field ...what should she have done?

Originalsly:
From the write up ...the requested drug was not dispensed by the machine. The override was activated. What happens when the override is activated? ...is it a substitute drug is dispensed? ... recommended? Is the nurse supposed to just administer the drug? ... or ch CK with the doctor.? People in the medical field ...what should she have done?

A glitch does not just occur. A glitch is a signal that something within the computer system does not sync. It could be the internet, a malfunctioned hardware, barcode issue, integration issue, software issue etc or operators ( nurse) error.
In this particular case. It seems the glitch was due to the mismatch detected between the right patient and the medication. This led to a manual override by the nurse. Nurses encounter these different glitches a lot and have become used to the manual override. It might not be her first time doing so.

There are no specific things to expect when there is a system glitch. Each situation is different. A range of different outcomes may happen in each event. Sometimes it could be that the drug dispenser will not open, if the scan is for the wrong patient ID (by ID, I mean the tag on the patient wrist) . But an override will allow the nurse to manually open the drawer, hopefully , it’s not that of a different patient.

Now, like every computer system, the cliche is “ garbage in garbage out”. If a nurse scanned the wrong patient ID, it will open the wrong patient medication dispenser. Also, if at the time of initial admission , the patient was given a wrong ID, the scanner will not identify the patient correctly. There are guardrails to all of these. The steps for proper patient identification is a must at each point of care.

Another scenario is that if the barcode on the dispenser is for a wrong patient, the disperser will not open or rather will only open that of that wrong patient but a manual override will open it for any patient. What if the dispenser is holding the medications of that other patient with that attached barcode?

Remember that majority of patients in admission are not alert and oriented. They are unaware of what medications they are being given. Even when alert, not every patient is knowledgeable in pharmacology . So the responsibility is for administration of the right medications is wholly on the nurse.

In addition, the nurse is responsible for taking down medications orders and reconciling them. Most elderly patient have multiple health issues and as such they are being given different many medications (poly pharmacy), sometimes from different doctors.This is the same for people with complex health conditions. With Electronic Medical Records (EMR) doctors could add, change dose or discontinue medications from a remote system. If the medications dispenser is not integrated with the EMR, the nurse may not be aware of these changes. By integration, I mean an electronic plugin that allows computers to communicate with each other. The absence of this arrangement could lead to error.

I don tire to write. Story still plenty!

Skydivine:
There are no specific things to expect when there is a system glitch. Each situation is different. A range of different outcomes may happen in each event.

I don tire to write. Story still plenty!

I wasn't expecting all this!.... but do appreciate! ... feel like a student! ... a slow one being taught by a very patient teacher! I had no idea the system was so pretty much automated. From what you wrote I'm thinking that if there was the need to override then she should've first double checked to see if she was doing something wrong ... as in verifying the patient bar code and whatever else. Then after overriding verify the medication is the one prescribed for the patient. I guess after this then it is safe to assume there may be a glitch in the system . I now want to believe she assumed there was a glitch (another one again) and didn't bother to cross check. This may be common ...but when something goes wrong ...as in this case ...all the rules of engagement and protection and punishment are dusted off and place under the spotlight..... enforcement to the max! Thanks again.....I learned something new today