Becker's Hospital Review

55 CMO / CARE DELIVERY were at the center of Ms. Vaught's case. Legal documents show she overrode the electronic medication cabinet aer failing to locate the sedative Versed. Typing "VE" into the search function, she had not realized the drug was listed under its generic name, midazolam. Ms. Vaught triggered the override to access a larger selection of drugs and accidentally withdrew vecuronium, a powerful paralytic. "One letter, two letters, or three letters is just not enough," Michael Cohen, president emeri- tus of the Institute for Safe Medication Practic- es, told Kaiser Health News. "For example [if you type] M-E-T. Is that met- ronidazole? Or metformin?" Mr. Cohen said. "One is an antibiotic. e other is a drug for diabetes. at's a pretty big mix-up. But when you see M-E-T on the screen, it's easy to select the wrong drug." Cabinet manufacturer Omnicell added the five-letter search function in 2020, though hospitals must opt in to the feature. Another cabinet company, BD, plans to make five-letter searches standard on its Pyxis machine aer a soware upgrade later this year. Once BD completes its update, most U.S. hospitals will have access to the features, as these two com- panies are the largest players in the medication cabinet industry. How leaders are responding Ms. Vaught's conviction should serve as a wake-up call for health system leaders to im- prove harm prevention efforts, the Institute for Healthcare Improvement said March 30. "We know from decades of work in hospitals and other care settings that most medical er- rors result from flawed systems, not reckless practitioners," IHI said. "We also know that systems can learn from errors and improve, but only when those systems encourage reporting, transparently acknowledge their mistakes and are held accountable for those errors." Aer the verdict, Los Angeles-based Ce- dars-Sinai sent staff a memo to encourage dia- logue around the issue and reassure employees that the health system was dedicated to keep- ing them safe, David Marshall, DNP, RN, the system's senior vice president and chief nurs- ing executive, told Becker's. e "ethical duty" of nurses to be honest in the face of errors was central to the message surrounding the sys- tem's response to the verdict. As of April 26, no nurses at Cedars-Sinai had quit over con- cerns about the verdict and what it means for the profession, according to Dr. Marshall. Along with encouraging error reporting, hos- pital and health systems must ensure they are giving nurses a platform to air any concerns in the wake of Ms. Vaught's verdict. "I'd also express gratitude for people bringing up their concerns about the verdict and en- courage them to talk to their manager if they want to talk further about it, or to me or any- one else in nursing leadership about what they were feeling," Dr. Marshall said. Dr. Marshall said the system stands with nurs- ing organizations that came out with docu- ments saying they believe medical error crim- inalizations would have "catastrophic" effects on healthcare. "We all drive down the highway at a higher rate of speed than is being posted sometimes, but making those types of errors in healthcare can have catastrophic results," Dr. Marshall said. "Being worried about that all the time was something we wanted to address." Several hospital CEOs from across the country have also weighed in on the topic to express support for nurses. Improving patient safety requires hospitals to have policies that protect employees who report mistakes. It also re- quires teams to have a collective ability to learn from those mistakes, Robert Garrett, CEO of Edison, N.J.-based Hackensack Meridian Health, and Kevin Slavin, president and CEO of Paterson, N.J.-based St. Joseph's Health, wrote in an April 18 column for Becker's. Industry leaders must support nurses — and all team members — as they are "working tire- lessly" to do the right thing, John Couris, pres- ident and CEO of Tampa (Fla.) General Hos- pital, wrote in a separate column for Becker's published April 28 . "is case is a cautionary tale, not just about the healthcare industry but all industries. We, as leaders, must create environments rooted in psychological safety where employees feel able to do their best work free from fear," Mr. Couris wrote. "e bottom line is that organi- zations should be spaces where everyone feels safe to express themselves, be open and hon- est, point out challenges and opportunities for improvement, and not be singled out for try- ing their best in an imperfect system." n Columbia University Medical Center cuts ties with Dr. Oz By Molly Gamble C olumbia University Medical Center has quietly cut its public ties to Mehmet Oz, MD, the TV celebrity physi- cian who is now a Republican candidate for a Pennsyl- vania Senate seat, WebMD reports. Dr. Oz held senior positions with the academic medical cen- ter, such as vice chair of the surgery department and director of integrated medicine. Now, Dr. Oz's faculty profile has been removed from the hos- pital's website and hyperlinks to his bio are disconnected on several pages that mention his name. His name no longer appears in website searches for physicians with the school's Irving Medical Center. In a listing for surgery faculty, Dr. Oz is listed as a "special lecturer" and still has office phone and fax numbers, but his listing is not linked to a faculty bio. Tension between the celebrity physician and the medical cen- ter goes back years. In 2015, after Dr. Oz testified before the Senate about his endorsement of "miracle" cures for weight loss, a group of 10 prominent physicians wrote to the school's dean of medicine to express dismay over his academic ap- pointments and to note he "has repeatedly shown disdain for science and for evidence-based medicine." A spokesperson for the medical center responded at the time to say Columbia is committed to the principle of academic freedom and to up- holding faculty members' freedom of expression. Dr. Oz's website for his political run describes him as "the host of the Emmy award-winning 'The Dr. Oz Show' and an Attending Physician at NY Presbyterian-Columbia Medical Center." n

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