| Recurring |
one_organization, multiple_organization |
(a) The software failure incident related to the medication mix-up at hospitals has happened again at Ballad Health, a chain of 21 hospitals in Tennessee and Virginia. Ballad Health activated the five-letter search feature on their Omnicell cabinets after the incident involving nurse RaDonda Vaught. The CEO of Ballad Health, Alan Levine, mentioned that many nurses were misspelling drug names, such as morphine, and the transition to the five-letter search feature revealed that even highly trained professionals can be bad spellers [127019].
(b) The software failure incident related to medication mix-ups at hospitals has also happened at other hospitals besides the one involving nurse RaDonda Vaught. According to a review of reports provided by the Institute for Safe Medication Practices (ISMP), there have been at least seven other incidents of hospital staffers searching medication cabinets with three or fewer letters and then administering or nearly administering the wrong drug. These incidents were reported by front-line health care workers to ISMP, indicating that similar incidents have occurred at multiple hospitals [127019]. |
| Phase (Design/Operation) |
design, operation |
(a) The software failure incident related to the design phase can be seen in the case of the medication cabinets used in hospitals. The incident involving nurse RaDonda Vaught occurred due to a flaw in the design of the medication cabinet software. The system allowed nurses to search for drugs with as few as two letters, leading to the selection of the wrong drug and resulting in a fatal dose being administered to a patient [127019].
(b) The software failure incident related to the operation phase is evident in the misuse or operation of the medication cabinets by hospital staff. Several incidents were reported where hospital staffers searched for medications with three or fewer letters and ended up administering or nearly administering the wrong drug due to the ease of selecting the wrong drug based on incomplete search terms. This misuse of the system during operation led to medication mix-ups and potential harm to patients [127019]. |
| Boundary (Internal/External) |
within_system |
(a) within_system:
The software failure incident discussed in the articles is primarily within the system. The failure occurred due to the design flaw in the medication cabinets' software, specifically the search functionality that allowed nurses to search for drugs with as few as one to three letters, leading to medication mix-ups [127019]. The incident highlights how the software design within the medication cabinets contributed to the errors made by hospital staff members, emphasizing the need for improvements in the software to prevent such mistakes in the future. |
| Nature (Human/Non-human) |
non-human_actions, human_actions |
(a) The software failure incident occurring due to non-human actions:
The incident described in the article is related to a software failure caused by a design flaw in the computerized medication cabinets used in hospitals. Specifically, the incident involved nurses being able to search for drugs with as few as two or three letters, leading to the selection of the wrong medication and potentially harmful outcomes for patients. The vulnerability in the software design allowed for the possibility of selecting the wrong drug based on incomplete search criteria, highlighting a non-human action contributing to the failure [127019].
(b) The software failure incident occurring due to human actions:
The software failure incident also involved human actions contributing to the failure. In the case of the nurse RaDonda Vaught, the initial error was made when she inadvertently withdrew the wrong drug from the cabinet after typing just two letters. This human action of selecting the medication based on incomplete search criteria set the stage for subsequent errors in administering the incorrect drug, ultimately leading to a fatal outcome for the patient. The incident underscores the importance of human actions in the chain of events that resulted in the software failure [127019]. |
| Dimension (Hardware/Software) |
software |
(a) The software failure incident occurring due to hardware:
- The article does not mention any software failure incident occurring due to contributing factors originating in hardware. Therefore, there is no information available to support this option.
(b) The software failure incident occurring due to software:
- The software failure incident discussed in the article is related to a medication mix-up caused by the software design of computerized medication cabinets. Nurses were able to select the wrong drug from the search results by typing in only a few letters, leading to potentially fatal errors [127019]. |
| Objective (Malicious/Non-malicious) |
non-malicious |
(a) The incident described in the article is non-malicious. It involved a nurse, RaDonda Vaught, who made a fatal medication error by selecting the wrong drug from a hospital's computerized medication cabinet due to the system's vulnerability in allowing searches with only two letters. This error led to the administration of a fatal dose to a patient. The software vulnerability that allowed this error was not intentionally introduced to harm the system but was a design flaw that persisted in many U.S. hospitals, leading to similar incidents [127019].
(b) The incident was not caused by malicious intent but rather by a software design flaw that allowed for the error to occur. The focus of the article is on improving the software systems in hospitals to prevent such errors in the future, indicating a non-malicious nature of the failure incident. |
| Intent (Poor/Accidental Decisions) |
poor_decisions, accidental_decisions |
(a) The intent of the software failure incident related to poor_decisions:
The software failure incident in the article was primarily due to poor decisions made in the design and implementation of the medication cabinets' software. Specifically, the incident where a nurse inadvertently administered the wrong drug was a result of the software allowing searches with only two or three letters, leading to confusion between similarly named drugs like metronidazole and metformin [127019].
(b) The intent of the software failure incident related to accidental_decisions:
The software failure incident can also be attributed to accidental decisions or mistakes made by hospital staff. For example, the nurse who administered the wrong drug did so accidentally after typing in just two letters, which led to the fatal medication error. Additionally, the article mentions instances where hospital employees mixed up drugs due to similar names, highlighting the accidental nature of these errors [127019]. |
| Capability (Incompetence/Accidental) |
development_incompetence |
(a) The software failure incident occurring due to development incompetence:
The incident involving the Tennessee nurse RaDonda Vaught giving a patient a fatal dose due to a drug mix-up was attributed to a software vulnerability in the computerized medication cabinets. The error occurred because nurses were able to search for drugs with as few as two or three letters, leading to the selection of the wrong medication. Safety advocates highlighted that requiring nurses to type in at least five letters of a drug's name could prevent such errors, emphasizing the lack of professional competence in the design of the software [127019].
(b) The software failure incident occurring accidentally:
The incident involving the nurse RaDonda Vaught giving a patient a fatal dose was described as a medical mistake that occurred due to a software vulnerability in the hospital's computerized medication cabinets. The error was unintentional and accidental, as Vaught inadvertently selected the wrong drug from the search results. The software flaw that allowed for such mistakes was not intentional but rather a design flaw that made it easy for users to make errors accidentally [127019]. |
| Duration |
temporary |
The software failure incident discussed in the articles is more related to a temporary failure rather than a permanent one. This temporary failure was due to contributing factors introduced by certain circumstances but not all. The incident involved a nurse inadvertently administering the wrong drug due to the software's search functionality allowing searches with too few letters, leading to medication mix-ups. The articles highlight how the software update requiring a minimum of five letters for drug searches was implemented to address this issue and improve patient safety [127019]. |
| Behaviour |
crash, omission, value, other |
(a) crash: The incident involving the Tennessee nurse RaDonda Vaught and the fatal drug mix-up can be categorized as a crash. The software failure in this case led to a critical error where the nurse inadvertently withdrew the wrong drug from the medication cabinet after typing just two letters, resulting in a fatal dose to the patient [127019].
(b) omission: The software failure incident can also be categorized as an omission. The failure occurred when hospital staff members searched medication cabinets with three or fewer letters and then administered or nearly administered the wrong drug due to the system omitting to perform its intended function of providing accurate search results based on the input [127019].
(c) timing: The software failure incident does not align with the timing behavior as described. The issue was not related to the system performing its intended functions too late or too early.
(d) value: The software failure incident can be categorized as a value failure. The system performed its intended function of displaying search results based on the input letters, but it did so incorrectly, leading to the selection of the wrong drug by the hospital staff members [127019].
(e) byzantine: The software failure incident does not align with the byzantine behavior as described. The system did not exhibit inconsistent responses or interactions in this case.
(f) other: The other behavior observed in this software failure incident is related to the need for a software update to enhance the search functionality of medication cabinets. The incident highlighted the importance of requiring nurses to type in at least five letters of a drug's name to prevent errors, indicating a need for system improvement to ensure patient safety [127019]. |