It is important to discuss the Omnicell issue in the #RaDondaVaught case. Many nurses are accustomed to Pyxis, where each medication bin pops open to dispense. Having used the Omnicell many times, the containers are open and next to each other. It is easy to select the wrong 1/
medication. Some of the bins have missing numbers and the flashing lights to help the nurse identify the medication doesn't always work or looks like the bin above the flash when it is indeed below. This is close to my heart because this has happened to my students before 2/
the only thing that prevented the error was the scanner in the room. There was no scanner in radiology. This case is also as much about the five rights as it is about other hot topics (like overriding, system failures, distractions, etc.). As much as we don't want 3/
to admit this, technology (while great) must work everywhere a patient might be.Modern nurses are only taught about the five rights in nursing school.The facility trains nurses to use the Omincell&scanners, but not the importance of completing the five rights in all situations 4/
Even the Omnicell skills check-off at Vandy doesn't include a review of the importance of the 5 checks before administering all medications. 5/ 
It is also worth mentioning that several cases like these have not resulted in the same criminal charges. The question remains, who will hold the technology companies accountable? Who will hold the facility's policies and practices accountable? 6/
We also need to discuss preceptorships, distractions, and post-medication monitoring in settings other than nursing units. There's a lot to unpack here. I'd like to do a Spaces soon. I'm just trying to get all the facts so I'm well informed! /End
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