Update on Omnicell variable character search feature

 As we have seen repeatedly, problems can occur with automated dispensing cabinet (ADC) drug name searches when just 2 or 3 characters are typed to select medications via override or from a non-profiled cabinet. This problem was illustrated most recently in our May 14, 2020, issue when a patient received verapamil instead of VERSED (a former brand of midazolam). A nurse used the cabinet override feature to select and access the drug “Versed” by entering the first few letters of the drug name. However, she accidentally selected and removed a vial of verapamil (5 mg/2 mL) from the ADC, which was available via override. Verapamil was then administered to the patient by IV push. The incident was strikingly similar to an earlier tragic error in which a patient died after receiving vecuronium instead of Versed after entering just “V-E” in the drug name search field.   

Searching drug names using just 1, 2, or 3 letters can lead to these situations, which is why we have recommended using at least 5 letters when searching for a drug in electronic systems. In the 2019 article cited above, we called upon ADC vendors to consider software changes to allow a configurable option for the required number of letters to narrow the choices, ideally to one drug or drug category. So far, we only know of Omnicell having such a feature (in the Omnicell XT ADCs), although BD/Pyxis has promised enhancements soon as well.

We recently learned a little more about how the Omnicell function works. The character search configuration is at the cabinet level and not at the individual drug item level. There is a series of tabs for clinicians to select the category of medication being removed, such as “Scheduled Meds,” “Active Med Orders,” “PRN Only,” and “Stocked Meds.” “Stocked Meds” is where the override function resides. If nurses access a medication via override, the cabinet can be set to address safety so that at least 5 letter characters must be entered to select a drug (Figure 1). The search functionality under “Scheduled Meds,” “Active Med Orders,” and “PRN Only” was not changed, so these do not require a 5-character search. Only medication searches for drugs obtained via override (“Stocked Meds”) require a 5-character search. Requiring a 5-character search for scheduled, active, and PRN medications may cause frustration and may not be required, as only medications prescribed and verified for the patient will appear during these drug name searches. We hope those who have Omnicell XT ADCs will make sure this important feature is set to require a 5-character search for drugs obtained via override.