Issue link: https://beckershealthcare.uberflip.com/i/1468749
29 PATIENT SAFETY & OUTCOMES A 5-letter fix for medication errors By Mackenzie Bean R aDonda Vaught's conviction for a fatal medication error has drawn newfound attention to the technological vulner- abilities of electronic medication cabinets, Kaiser Health News reported April 29. Ms. Vaught was convicted March 25 of criminally negligent homicide and abuse of an impaired adult for a fatal medication error she made in December 2017 while working as a nurse at Vanderbilt University Medical Center in Nashville, Tenn. She was sentenced to three years of supervised probation May 13. Legal documents show Ms. Vaught overrode an electronic medication cabinet aer failing to locate the sedative Versed. She had typed "VE" into the search function, not realizing the drug was listed under its generic name, midazolam. Aer triggering the override to access a larger selection of drugs, Ms. Vaught accidentally withdrew vecuronium, a powerful paralytic. At least seven other instances in which hos- pital employees administered or nearly ad- ministered the wrong drug aer typing three letters or fewer into medication cabinets have occurred since 2019, according to KHN's analysis of documents from the Institute for Safe Medication Practices. is figure is likely a gross undercount, as hospitals are not mandated to report most drug mix-ups. To prevent these errors from occuring, safety advocates say nurses should be required to type at least five letters of a drug's name when searching in electronic medication cabinets. Cabinet manufacturer Omnicell added the five-letter search function in 2020, though hospitals must opt in to the feature. BD, another cabinet company, plans to make the five-letter search standard on its Pyxis ma- chines via a soware upgrade later this year. BD and Omnicell are the largest players in the medication cabinet industry, meaning most hospitals in the U.S. will have access to a five-letter search feature once BD completes its update. While the change will make it slightly less convenient to withdraw drugs — requiring nurses to know how to spell complex drug names — it will provide another layer of protection against errors. A five-letter search would lead to an "ex- ponential increase in safety" when pulling drugs from electronic medication cabinets, according to Erin Sparnon, an expert on medical device failures at the nonprofit safety organization ECRI. "e goal is to add as many layers of safety as possible," she told KHN. "I've seen it called the Swiss cheese model: You line up enough pieces of cheese and eventually you can't see a hole through it." n Where are the 22 Leapfrog straight-'A' hospitals? By Erica Carbajal T he Leapfrog Group released its spring 2022 Hospital Safe- ty Grades on May 10, assign- ing "A" through "F" letter grades to nearly 3,000 general acute care hospitals in the U.S. for patient safety performance. Since 2012, Leapfrog has assigned letter grades to hospitals based on their ability to protect patients from preventable errors, accidents, injuries and infections. Grades are based on more than 30 national performance measures from CMS, the Leapfrog Hospital Survey and other supplemental data sources. Twenty-two hospitals have achieved 21 consecutive "A" grades since the launch. In the fall, 23 hospitals achieved 20 consecutive "A" grades. This year, OSF St. Mary Medical Center in Galesburg, Ill., received a "B" grade after 20 consecutive years of earning an "A." Here are the 22 hospitals that have achieved 21 consecutive "A" grades: Arizona Mayo Clinic Hospital (Phoenix) California French Hospital Medical Center (San Luis Obispo) Kaiser Permanente Orange County Anaheim Medical Center Sierra Vista Regional Medical Center (San Luis Obispo) Colorado Rose Medical Center (Denver) Florida AdventHealth Daytona Beach Illinois Elmhurst Memorial Hospital Northwestern Medicine Central DuPage Hospital (Winfield) University of Chicago Medical Center Massachusetts Beverly Hospital Saint Anne's Hospital (Fall River) Michigan University of Michigan Health (Ann Arbor) Mississippi Baptist Memorial Hospital Golden Triangle (Columbus) North Carolina Rex Hospital (Raleigh) Ohio OhioHealth Dublin Methodist Hospital OhioHealth Grady Memorial Hospital (Delaware) Texas St. David's Medical Center (Austin) Virginia Inova Loudoun Hospital (Leesburg) Sentara CarePlex Hospital (Hampton) Sentara Leigh Hospital (Norfolk) Sentara Williamsburg Regional Medical Center Washington Virginia Mason Medical Center (Seattle) n