Device Data Part 1: Case Study

This post is Part 1 of a series based on Nursine Jackson’s article, “What about that Device Data?”.

Device Data Case Study

A nurse in Tennessee received a communication that one of her patients was in radiology waiting for a CT, but too stressed to hold still for the study. Her patient’s physician had issued an order for a sedative, Versed, to help her through the examination. This nurse went to the cabinet to retrieve the medication ordered. She typed in “V E” and a medication name autofilled with “VERCURONIUM,” to which the nurse hit “accept.”

Vercuronium is not Versed; Vercuronium is a paralytic agent used by anesthesia personnel and used only when a patient has ventilatory support, because it paralyzes the muscles involved with breathing. Since Vercuronium was not a drug typically dispensed to patients on a medical surgical unit, this nurse had to override a series of warnings in order to open the drawer on the medication dispensing cabinet to retrieve the medication. This nurse was busy - and very familiar with those pesky alerts and alarms that she had to constantly circumvent in order to complete necessary tasks throughout her every workday. We do not know what she was thinking as she took the steps to override the multiple warnings, but we know that she, unfortunately, successfully accessed the vercuronium. She then ran down to radiology to administer the paralytic agent intravenously.

As the story goes, after she administered the medication, she left without monitoring this patient. As the patient was undergoing the radiology study, no one appreciated that she had stopped breathing. No one appreciated that this paralyzed woman had a problem until they found her – lifeless – after completion of the imaging.

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Where did the hospital find answers about how this medication error caused an unexpected death?

Important insights were within the device data preserved on the medication dispensing device. This device, identified as an Omnicell®, is much more than a medication supply cabinet. It is also a very sophisticated computer, driven by software that records information about activity within the system, recording the steps taken by the nurse to access the medication. Before administering a medication in a barcoded medication administration system (BCMA), the nurse must scan the barcode on:

• every medication

• for each patient

• themselves as the drug administrator

• and if the drug were to be administered via pump, then the pump must also be scanned.

Each of these actions is preserved by the device and stored elsewhere.

In this real-life medical drama, the preserved device data told the story about how the nurse accepted the name of the wrong medication that had auto-filled, then she proceeded to override all of the alerts and alarms triggered by her attempts to access this very unusual medication for a patient on a medical surgical floor. [1]

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This Vanderbilt University Medical Center nurse has been charged with criminal homicide.

Knowing the facts of this story should help Plaintiffs’ advocates seek evidence relevant to their own cases. First, many devices utilized in the course of patient care have software that is recording and preserving potentially invaluable information that could illuminate the facts relevant to the legal investigation. Secondly, even though hospitals deny that this data is preserved or available, this story illustrates that when it is the hospital who needs access to the electronic data to defend themselves, they are capable of producing it.

Conveying the facts of this Vanderbilt story could be useful in convincing a judge that this critical device data exists – and like other data preserved in audit trails, may yield key information not available in any other part of the medical record.

Know though, that if the device were not properly associated with the electronic medical record (EMR), the presence of the device might not be included in the audit trail produced from the EMR. Also remember that filing early preservation motions for device data may protect and/or assist the plaintiff’s team in gaining access to important eDiscovery in your case.

Stay tuned for Part 2 of Nursine Jackson’s article, “What is Device Data?”.

[1] Blog Administrator. (2015, September 23). How are you managing automated dispensing cabinet overrides? Transform healthcare: an informational blog for healthcare professionals presented by Omnicell. Retrieved from https://transform-healthcare.com/2015/09/23/how-are-you-managing-automated-dispensing-cabinet-overrides/