When Good Safety Intentions Go Bad

It would be nice if the magic (if expensive) solution to dangerous errors in hospitals were largely a matter of bringing in technology like electronic medical records and bar-code readers. But, as an entry by a nursing consultant on a patient safety listserv run by the National Patient Safety Foundation reminded me, adding seemingly fail-safe technology is no guarantee that harried people will use it properly. Take, for example, how medications are distributed to patients.

Many hospitals now use automatic dispensing machines to ensure that the right patient gets the right drug in the right dose. Each patient's information and medications are stored in the computerized device, which unlocks when a nurse enters the correct information on a keyboard or touchscreen and makes the drugs available, each one labeled with the patient's name.

So far so good. Most of the time, however, the machine sits in one spot. Nurses are busy, and at hospitals where there aren't enough of them—quite a few—they have to hustle. To keep from having to make a round trip to the cart for each patient, it's tempting to take out medications for more than one patient, put the drugs on a tray or cart, and dole them out patient by patient. Some nurses succumb. Of course, that completely voids the security provisions of the automatic dispenser. But can you blame them?