Nurse Gives Lethal Dose of Vecuronium Instead of Versed - page 2

PET scans are typically performed in the outpatient setting and not inpatient. They are not emergent. This was a full body inpatient PET scan which might be said is inappropriate resource... Read More

  1. by   Nurse Beth
    The nurse made an EGREGIOUS error that cost a patient her life.

    But if the only solution is to remove the nurse from the equation then we've lost an opportunity to improve. There's lessons to be learned.

    What if Vanderbilt had protocols in place around administering conscious sedation? Such as training to include patient monitoring.

    What if the ICU nurse who delegated this task to the "help all nurse" followed the proper rights of delegation? (right task to right person)

    What if there was not a culture of expediency, to get the job done at all costs, and hurry up? What if the procedure had been rescheduled while the pt given po anxiolytic? Btw, I've seen GI docs push assistants to shorten the cleaning time for scopes. And the overwhelmed assistants complied.

    What if there was a clear job description with qualifications and training for the "help all nurse"?
  2. by   Wuzzie
    Quote from Nurse Beth
    The nurse made an EGREGIOUS error that cost a patient her life.

    But if the only solution is to remove the nurse from the equation then we've lost an opportunity to improve. There's lessons to be learned.

    What if Vanderbilt had protocols in place around administering conscious sedation? Such as training to include patient monitoring.

    What if the ICU nurse who delegated this task to the "help all nurse" followed the proper rights of delegation? (right task to right person)

    What if there was not a culture of expediency, to get the job done at all costs, and hurry up? What if the procedure had been rescheduled while the pt given po anxiolytic? Btw, I've seen GI docs push assistants to shorten the cleaning time for scopes. And the overwhelmed assistants complied.

    What if there was a clear job description with qualifications and training for the "help all nurse"?
    I work at a facility that could be considered equivalent to Vanderbilt. There ARE guidelines for sedation mandated by law. They require monitoring and staff education. So we know those were in place and ignored. As far as delegating to the right person. As a nurse I am ethically and professionally responsible to SPEAK UP if I am uncomfortable or untrained to do a task delegated to me. It isn't unreasonable to think that a nurse trained at the same level as I am is equipped to do the same job I do. Every facility I have worked at has some sort of resource nurse (or help-all nurse if you prefer). These nurses, across the board, have been seasoned critical care nurses who are capable of doing any task asked of them. Because of this the onus is on THEM to only do those things they are trained to do. Given the choice of refusing an unfamiliar procedure or winging it, as this nurse did, the prudent nurse will always err on the side of caution. This is a huge university health system not some fly by night operation. I guarantee you they have ALL the policies you speak of in place and hundreds more. Take this nurse out of the equation and the patient. would. not. be. dead!
  3. by   smf0903
    If the order was reviewed by pharmacy, why was it not profiled? This would have eliminated the need for an override. That being said you still have to know what you're giving and that it matches an appropriate order. Pharmacists are human as well and I have seen things stocked incorrectly in pyxis bins, so you can't just pull something and assume it's correct.

    The ball was dropped every step of the way on this.
  4. by   mtmkjr
    Quote from Wuzzie
    I don't at all get your premise that this was an unnecessary test done in the wrong setting. Or that had it been done outpatient no sedation would have been ordered.

    I see two two and only two issues here. The nurse was shockingly incompetent and the Pyxis system should not have allowed an override of such a dangerous drug.

    The nurse omitted 4 of the 7 rights of medication administration. And while training another nurse to boot. And she ignored all of the warnings on the Pyxis as well as on the vial. Just disregarded them. Furthermore no patient receiving Versed should be left un-monitored. Even if it's just eyes-on. No nurse in their right mind would administer such a medication and then walk away. There simply is NO excuse for that. None! That she administered Vecuronium instead of Versed actually has little to do with it. Certainly not 2mg of it. If she had monitored the patient properly even that accidental dose of Vec wouldn't have killed the patient. She would have seen what was happening and intervened. The patient could have just as well died from the Versed. This wasn't an isolated med error. Most of us have made one of those. This was a major practice error made by a nurse who clearly didn't have the sense God gave a cardboard box. I'm all for using these situations as teaching moments but come on. We need to call it what it is. A nurse with a huge knowledge deficit doing a job she was ill-equipped to do and who demonstrated a shocking lack of basic good judgement.

    Combine that with...

    A machine that should never have been programmed to allow an override for such a dangerous med. Ours are programmed only to allow override for things like NS, D50, Epi ampules. No narcs, benzos and most definitely not paralytics.

    I agree with Katie.
    And to top it off she was teaching someone else!
  5. by   Nurse Beth
    Here is the CMS report Not Found | DocumentCloud. Looks like the link does not work here.

    I read the full CMS Vanderbilt report and it's surprising to read there was no job description for the "help all nurse" and there "was no policy of procedure regarding the manner and frequency of monitoring patients after medications were delivered"

    I'll try to provide a link, but I obtained it from a link in Twitter. Doesn't seem to work here.
    Last edit by Nurse Beth on Dec 1
  6. by   Ddestiny
    Quote from TigraRN
    Mandatory double verification would be helpful for paralytic as well. If we have another RN witness insulin, heparin, amio, why not do the same with vecuronium?
    This is definitely a good idea, but unfortunately it would not have saved this pt as she did not scan the med. Just scanning it would have given her a hard stop since the Vec wasn't ordered. That also makes me wonder, would she have not scanned the Versed? Playing with controlled substances is no joke either, though an undocumented dose of Versed would have had a much better outcome for this patient. Awful situation all around.
  7. by   Nurse Beth
    Quote from Ddestiny
    This is definitely a good idea, but unfortunately it would not have saved this pt as she did not scan the med. Just scanning it would have given her a hard stop since the Vec wasn't ordered. That also makes me wonder, would she have not scanned the Versed? Playing with controlled substances is no joke either, though an undocumented dose of Versed would have had a much better outcome for this patient. Awful situation all around.
    I wonder if there was bar code scanning capability in the PET scan room
  8. by   smf0903
    I tried a link to CMS report as well, but it didn't work.

    I read through the entire CMS report and all I can say is that entire situation was completely messed up.
  9. by   adventure_rn
    To play the devil's advocate, in my PICU setting we override and give paralytics all of the time; we'd be in a real bind if paralytics came from pharmacy only, as our peds cardiac patients have a tendency to flip out, bear down, have pulmonary hypertensive crises, and actively try to die within about a 2-minute span. I'd say that on a weekly basis, we have to give paralytics (plus sedation) at a moment's notice to combat pulmonary hypertension and prevent codes; granted, many of our patient's requiring paralytics have a standing PRN paralytic ordered, and they're obviously all intubated...

    I do agree that there are a lot of errors in this scenario (both personal and systemic); however, I don't think that preventing a paralytic override from the pyxis is necessarily the answer. Perhaps it would make sense to only be able to override paralytics in the ICU or OR suite, but honestly, if I were in CT or MRI with one of my patients, I'd want to have the option to override roc or vec at a moment's notice.
  10. by   blondy2061h
    Quote from KatieMI
    P.S. murseman24, I think that, if patient was indeed given vec instead of Versed, she was given exactly 2 mg. Lethal dose of vec would cause respiratory arrest within less than 5 min (time to start for vec is 1 min and time max action 3 to 5 min) and death within less than 10 min total. Should it be so, she wouldn't get back to ROSC in 2 cycles of CPR. Moreover, whatever they were PETing her for, energy consumption picture, which is the principle PET works on, would change radically and immediately. If she had ROSC after just 2 CPR cycles, it means that after 30 min she was only half dead, that is to say. Which means she had some time laying there and getting out of this world, and therefore it must not be whole vial of vec given.

    But then it was not lethal dose. Mistake, yes. Lethal per se, no.
    This is what I don't understand about the timeline. 30 minutes since she got the vec when the code was called and they got her back with 2 rounds of acls? But she was so hypoxic she was declared brain dead within 24 hours?

    As far as job descriptions go she probably had a general RN job description but specific to the helper role.
  11. by   RNrhythm
    What a nightmare. Often these off-unit administrations are unscanned. You may run down to MRI with some Ativan but there is no workstation equipped with a scanner. That always make me nervous and I am very careful.
  12. by   blondy2061h
    Quote from Wuzzie
    I don't at all get your premise that this was an unnecessary test done in the wrong setting. Or that had it been done outpatient no sedation would have been ordered.
    I don't understand that either. If she was sick enough to require an ICU or a SDU clearly she wasn't appropriate to have an outpatient test. Sometimes a PET scan is required to guide treatment plans. Working in oncology I have seen many an inpatient get a PET scan.

    And yes, outpatients get sedation but it's usually PO. Vecoronium doesn't come PO, but if the nurse got this far in this error, who is to say they wouldn't confuse the route also?
  13. by   JKL33
    Quote from Nurse Beth
    What if Vanderbilt had protocols in place around administering conscious sedation? Such as training to include patient monitoring.
    You have mentioned conscious sedation (aka moderate sedation) a couple of times; just want to mention this was not the intent of that order. It was an anxiolytic dose of midazolam (minimal sedation/anxiolysis). I understand your point though - anyone who works with any of these meds should have the appropriate procedural sedation training.

    Quote from smf0903
    If the order was reviewed by pharmacy, why was it not profiled? This would have eliminated the need for an override.
    The order (for Versed) had been verified by pharmacy, so presumably it was profiled. The nurse reported to CMS investigators that she searched for Versed under the patient's profile. If you are working (searching) within a list of generic names, Versed obviously is not there. The nurse then went into override mode and searched "ve."

    Quote from Ddestiny
    This is definitely a good idea, but unfortunately it would not have saved this pt as she did not scan the med. Just scanning it would have given her a hard stop since the Vec wasn't ordered. That also makes me wonder, would she have not scanned the Versed?
    This is an assumption, but since med scanning technology was not present in the PET scan area, the med likely would not have been scanned regardless what it was.

    The rest of my comments are on the thread in the Nursing News forum from earlier in the day.

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