Vanderbilt is having a rough patch. First the lethal Vecuronium error and now a "never event".
A woman at Vanderbilt undergoing kidney surgery suffered a wrong-site surgery to her kidney- a "never event". She filed a 25 million dollar lawsuit due to extensive damage and is now dependent on dialysis. Neither here nor there, but one news report said the woman was a certified nursing assistant (CNA).
In the first case, the RN was arrested and charged with reckless homicide. Should the surgeon likewise be arrested and face charges?
Have you ever pulled a med from the Pyxis? Because that isn't how they work. You think at the first drug you pull up after only a couple of letters is even 99% of the time the right one?
Well, it's not.
Historically that is basically how they have worked during various iterations in different places. A list is/was immediately produced based on what you start typing. Of course, the more letters you type the shorter the list becomes, but often enough the thing wanted appears at the top of the list after just a couple of letters, so that is what people became accustomed to. It seems like it used to also have something to do with what was most frequently-used as well, but I never had reason to verify that idea, and things have since changed.
That's why it has been noted or asserted that when commonly-used meds appear farther down the list, the "pick the first thing" habit is broken. For instance, it used to be that when I typed "sod," 0.9 NS 1L would appear at the very top of the list. Now it has been changed to appear about half-way down the screen, even though it is by far the most common thing that people in my area want when they type "sod."
I am not completely sure if this was an intentional safety measure or if the list of items I see has simply changed for other reasons and now 0.9 NS 1L just happens to be farther down the list, but either way it forces people to actually read and choose, rather than rotely tapping what appears at the top.
Rote tapping out of habit and "confirmation bias" ("seeing" what it is that you know you want, and tapping on it even though it is something else) are both ideas that have been addressed by the ISMP.
Does it matter if it was an RN or a Doctor who made a life changing error? Sure, yes, it does.
An Rn is responsible for administering medications, and should ensure it is the right does, right patient, etc.
A doctor is taking out a kidney. He should know which one. He gets paid at least 5-10x our salary to ensure the right organ is coming out. Why would any of you turn this into a nurse drew Vecuronium to a doctor taking out a kidney. Both were mistakes by humans. Both were in the same system. How dare you. Shame.
Perhaps the blame does belong to the system and not so much on the individual employees. Don't you dare draw a comparison, since so many were so eager to hang this nurse out to dry. Do the same for the doctor, or at least acknowledge there is a fault in the system.
It can be said most all mistakes, especially within a hospital, are failures of the system. This is a large reason why incident reports and event reviews are not supposed to be punitive.
If the system was perfect a human could not physically make a mistake.
Unfortunately systems are built with hard and soft guardrails. Hard designed systems are things like car keys, you must have car keys to start the car. Soft designed items are things like seat belts, they require active compliance of the user.
Mistakes happen but when professionals who are educated and trained to deal with complex issues either ignore or override established safety measures and cause harm, well that is an entirely different thing.
Mistakes happen but when professionals who are educated and trained to deal with complex issues either ignore or override established safety measures and cause harm, well that is an entirely different thing.
Sure, and there are no fail safes to ensure it's the right organ, right patient, right side, and right part taken out. Please, show me your comparisons and how failsafes aren't in place for medicine.
Do you really consider that doctors do no wrong? Is there not a service you wouldn't allow to operate on you, or a doctor that you have told your significant other, just let me die rather than have them operate. If so, then your comment is null and void.
It can be said that it is a standard of practice to monitor and assess the patient for adverse reactions regardless of the medication. Considering the the method of delivery and the type of medication, IVP meds may necessitate a greater level of assessment.
Yes. And certainly even if the med administered was Versed - which is what the nurse believed was being administered, any drug reference will mention the "monitoring" (aka surveillance) required for that medication: "Have resuscitation equipment available and monitor patient closely until effects of IV administration are known" (Epocrates). Since the top two adverse effects (> 10%) are "decreased respiratory rate" and "apnea," I can't imagine any reasonable reference would omit the special/specific monitoring (surveillance) required.
Sure, and there are no fail safes to ensure it's the right organ, right patient, right side, and right part taken out. Please, show me your comparisons and how failsafes aren't in place for medicine.
Do you really consider that doctors do no wrong? Is there not a service you wouldn't allow to operate on you, or a doctor that you have told your significant other, just let me die rather than have them operate. If so, then your comment is null and void.
From the little information I have seen I think the physician is very much in the wrong. Honestly though, I have not seen much beyond a vague news story.
If he went over the fail safes then he should 100% be charged with a criminal charge.
I am guess that in the medication error case the patient death and subsequent criminal charges was far more sensational allowing for more advertising revenue than a wrong site surgery which as horrible as it is, is not uncommon.
I directly quoted Clebak’s question in my response so I’m not sure what you’re getting at.
Oh and your snark did not go unnoticed, I’m currently searching for some aloe. Might need to run to the store. ?
There really wasn't any snark intended, I was trying to offer that there was an understandable reason why you didn't respond to the question instead of just saying you were intentionally ignoring it.
Have you ever pulled a med from the Pyxis? Because that isn't how they work. You think at the first drug you pull up after only a couple of letters is even 99% of the time the right one?
Well, it's not.
99.3% to be exact, although there are certain first-two-letter combinations that are more common which brings it down, but it's still "most" (greater than 50%). You are correct that it's by no means a consistently reliable method, which is why it's prone to picking the wrong med.
It’s not 1:1 monitoring. It’s waiting a minute or two and watching for an adverse reaction and it is standard of practice. It has never been acceptable practice to give an IV push med and just walk away, certainly not slam it in and walk away.
I'm not sure where you're getting the "slam it" description for the RV incident, but no, it's not the legal standard of practice.
I think we often confuse the vernacular use of 'standard of practice' and 'reckless' with the legal definitions. A failure to follow the legal standard of practice is defined as a practice which cannot be found in typical practice, and while it certainly could be argued that it's better to provide continuous direct monitoring after giving any IV med, it's not particularly difficult to find frequent instances where nurses give an IV med then move on to the next task with the reassessment to come later, which makes far from a legal standard of care.
Whoever asked that question was an idiot, because if you pull up the definition in the state statute, it meets ALL of the criteria. It also matches it per definition in the Black's Law Dictionary.
Tennessee legal statutes defines 'reckless' as a gross deviation from (common) practice. This would mean that every instance where a nurse uses the override function could result in a criminal charge of reckless endangerment. The DA's charge is based on the premise that the override function is never used in the process of appropriate practice, which isn't accurate at every place I've worked.
JKL33
7,041 Posts
Historically that is basically how they have worked during various iterations in different places. A list is/was immediately produced based on what you start typing. Of course, the more letters you type the shorter the list becomes, but often enough the thing wanted appears at the top of the list after just a couple of letters, so that is what people became accustomed to. It seems like it used to also have something to do with what was most frequently-used as well, but I never had reason to verify that idea, and things have since changed.
That's why it has been noted or asserted that when commonly-used meds appear farther down the list, the "pick the first thing" habit is broken. For instance, it used to be that when I typed "sod," 0.9 NS 1L would appear at the very top of the list. Now it has been changed to appear about half-way down the screen, even though it is by far the most common thing that people in my area want when they type "sod."
I am not completely sure if this was an intentional safety measure or if the list of items I see has simply changed for other reasons and now 0.9 NS 1L just happens to be farther down the list, but either way it forces people to actually read and choose, rather than rotely tapping what appears at the top.
Rote tapping out of habit and "confirmation bias" ("seeing" what it is that you know you want, and tapping on it even though it is something else) are both ideas that have been addressed by the ISMP.