Legal UpdateJune 2022
Deadly Autocorrect!Recently, I found myself writing a text to a physician colleague, Dr. Verma. I typed in “Ve” on my phone, pressed “return,” and began compiling my note to him. Before I pressed send, I noticed that my text was about to be sent to another attorney colleague, Ms. Velasquez, who would have thought the text was very odd and out of context. This certainly would not have been the first time I was texting with someone when the wrong word or phrase was inadvertently texted to someone in the haste of busy schedules and rapid-fire texting capabilities. Besides some brief embarrassment and perhaps a chuckle by both parties, I never contemplated that the usually helpful autocorrect function may be a deadly contributor to a patient’s death. By now, many of you have likely heard the unfortunate story of nurse RaDonda Vaught (nurse Vaught), the Vanderbilt University nurse who in 2017 inadvertently gave Vecuronium instead of Versed to a patient needing sedation for some imaging procedures. How could this have happened? If any of you have been in the pharmacy room while nurses are pulling medicines, you may have noted they will type in the name of the medication they want and many “pyxis” type systems will auto-populate the remainder of drug names beginning with “Ve,” for example. The drugs will usually present themselves in alphabetical order, hence VECuronium will display before VERsed. This was apparently the initial fatal mistake that led to the death of Ms. Charlene Murphey (Ms. Murphey) in the Vanderbilt hospital. While Ms. Murphey was undergoing some claustrophobic imaging procedure for a recent subdural hematoma, her doctors ordered some versed for sedation. Nurse Vaught inadvertently obtained the long acting paralytic, vecuronium, from the medication dispensing device instead. As you can imagine, the 30 minutes of paralysis that ensued during Ms. Murphey’s imaging procedures did not bode well for her outcome. She succumbed to her hypoxic event in the following hours. Nurse Vaught and a nursing colleague soon realized her mistake and readily came forward with the revelation. Nurse Vaught was arrested in 2018 and charged with (1) gross neglect of an impaired adult and (2) reckless homicide. Nurse Vaught was subsequently convicted of the first charge above and of criminally negligent homicide, a lesser included offense of the 2nd offense above. Criminal charges for medical errors are an extremely rare event in the practice of medicine. While we expect to run across civil complaints in the course of our careers, none of us ever anticipate the prospect of jail time for a job-related criminal conviction. Given the potential of criminal charges in the course of our careers for seemingly common mistakes, what do you foresee will be the outcome of this singular verdict? Without a whole lot of brainstorming, I can foretell that many nurses that were contemplating retirement during the recent COVID pandemic, will see this court decision as the push they needed to exit the profession forever. Furthermore, those folks that were ever contemplating entering the nursing profession may be dissuaded by the overwhelming risks versus benefits of a career in nursing. What about the additional landmines that have now been precedented for those EM docs administering medications in the course of our practice. I’m going to bet you take another look at the similarly looking red-topped bottles of Lidocaine with epi and vecuronium or how similar the yellow-topped bottles of rocuronium and midazolam appear! Unfortunately, the same medication, midazolam for example, can have varying colors that can lead you astray as to the contents of the bottle. Obviously, looking at the name on the bottle is the ideal way to ensure the patient gets what you want, but there could also be other visual or audible ways to preclude inadvertent medication administrations. For example, the ophthalmology industry has color coded the tops of their bottles to coincide with the different classes of eye drops. How about a pyxis machine that audibly announces the name of the medication you are withdrawing from the device? Unfortunately, this case uncovers just one of the many landmines that looms out there for us as ED practitioners and for our patients. Most of the time the “autocorrect” functionality is quite helpful, but other times I wonder whether I should just turn off the functionality. After this awful case, I’m inclined to put this technology on the back burner. I hope everyone is staying safe and returning to some semblance of normal craziness in the ED. Kenneth Alan Totz, DO, JD, FACEP No information within this publication should be construed as medical or legal advice. Independent medical and/or legal advice should be sought based on each individual’s particular circumstances. |
