Anesthesiologist Group Says Hospitals Can Prevent Fatal Errors Like Vanderbilt's

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by sirI sirI, MSN, APRN, NP (Admin) Educator Columnist Innovator Expert Nurse

Specializes in Education, FP, LNC, Forensics, ED, OB.

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mtmkjr, BSN

350 Posts

3 hours ago, CommunityRNBSN said:

YES YES shout this from the rooftops. 

I work outpatient. There are no medications on the premises that could possibly do serious harm. And yet, Every Single Task I perform using our eMR gives me a series of bright red warnings. “This patient is on Prozac. RISK FOR SEROTONIN SYNDROME.  DO YOU REALLY WANT TO SEND THIS MED.”  “This patient is on warfarin. DID YOU DISCUSS BLEEDING DANGERS.”  “This patient has a history of depression. DID YOU ASSESS FOR SUICIDALITY.”  I have to click “acknowledge” multiple times on bright red warning boxes to accomplish the simplest of tasks. When someone says “But RV overrode a paralytic warning!” I just roll my eyes. 
 

I was always sympathetic to the fact that Radonda overrode the Pyxis warning. THAT I can relate to, and agree 100% with Emergent on THAT being a huge problem. 

If only that had been the only thing. If only she had then looked at the vial and said, "😱 how did I end up with vecuronium in my hand?! "

Edited by mtmkjr

CommunityRNBSN

CommunityRNBSN, BSN, RN

Specializes in Community health. Has 4 years experience. 801 Posts

1 hour ago, mtmkjr said:

 

If only that had been the only thing. If only she had then looked at the vial and said, "😱 how did I end up with vecuronium in my hand?! "

100%, I agree with that as well. There’s no excuse for not knowing what med you are giving. 

klone, MSN, RN

Specializes in OB-Gyn/Primary Care/Ambulatory Leadership. Has 16 years experience. 14,248 Posts

On 6/18/2022 at 7:57 AM, ThePrincessBride said:

I don't think a med like vec should he easily accessible. It should require two nurses to pull and 2 nurses to give or it needs to be Stat or ordered from pharmacy.

I mean, if you have to double sign heparin drip changes, you should have to dual sign a paralytic.

It’s needed an emergent situation for RSI. Requiring pharmacy or to nurse nurse sign off would put people in danger.

Emergent, RN

Specializes in ER. Has 29 years experience. 2 Articles; 3,982 Posts

Yes, it does boil down to the simple fact that all nurses need to look at the medication, and verify that they are giving the correct one. I've caught myself before by reading the vial. I looked at it and said "Oh I took the wrong medication out, how could that have happened? I had better put it back and start over!"