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Table 7.4 of your Heizer/Render/Munson textbook lists examples of the use of technology in health care and other service industries. One technology in health care that is often used in hospitals is the computerized medication cabinet also known as the automated dispensing cabinet. (See page 215 for an example). These drug cabinets offer a number of advantages over the former non-powered old-school medication carts, but can lead to serious problems when the wrong drug is selected. Unfortunately, hospitals are not required to report when wrong drugs are administered so we do not know the depth of the problem. (A nurse in Tennessee was recently prosecuted for wrongful death when she selected the wrong drug).
The current process requires the nurse to enter the first 3 letters of the drug that they want. Safety advocates want at least 5 letters to be entered to reduce or avoid confusion and the cabinet makers are currently in the process of making the change to require 5 letters. While a 5 letter requirement seems better than 3 letters from a safety standpoint, requiring more letters leads to problems other than safety. This will require that nurses can correctly spell names of difficult pharmaceuticals. Sometimes these drugs are needed in chaotic emergency situations and using 5 letters instead of 3, while intended to improve safety, will slow the process down. Of course, three letter names can cause spelling problems, for example, if the nurse is unsure whether the drug begins with “ph” or “f”.
The general goal when dealing with dispensing drugs is to have as many layers of safety as possible. This is sometimes called the Swiss cheese model. The holes in Swiss cheese do not generally align so having enough pieces of Swiss cheese will prevent a mistake from going through all of the holes. The 5 letter requirement is a better slice of cheese than the 3 letter requirement.
This Swiss cheese approach of adding layers for safety is similar to web sites requiring a code sent by text to be entered in addition to entering your name and password. The CDC has essentially been using a Swiss cheese model for COVID protection, as seen in the figure.
As a final note on reliability, many hospitals still maintain the old-school carts as a backup in case of a power failure.
Classroom discussion questions :
- What industries, other than healthcare, use a Swiss cheese approach?
- If requiring 5 letters is better than requiring 3 letters, wouldn’t requiring 6 letters be better than 5 letters?