Nurse Gives Lethal Dose of Vecuronium Instead of Versed - page 4

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   blondy2061h
    Quote from Here.I.Stand
    I'm sure the nurse is beyond-words devastated over this....

    But it's nursing school 100... one of the VERY first things a nursing student learns is the 5-7 rights of med administration!!

    What the actual what?? Yes I understand things don't happen in a vacuum, but I'm sorry ... the RN -- the last line of defense -- didn't check the **** vial. S/he was negligent.

    We are never SO busy that the <30 seconds it takes to check our **** meds will hurt anyone

    Conversely, her/his negligence cost a person's LIFE. The pt who depended on professionals' safe practices.... and who must have suffered indescribable agony and terror for several minutes before the end.
    The RN may be the last line of defense, but by overriding the med she went ahead and bypassed ever other line of defense and made herself the only live off defense.
  2. by   blondy2061h
    Quote from kat7464
    Best advice I was ever given came in nursing school - always ask yourself, "Does this make sense?" before doing anything to the patient. This made no sense on many levels and the nurse should have stopped in her tracks before administering that drug.

    They clearly didn't know enough about vec of versed to know if it made sense
  3. by   Nurse Beth
    [QUOTE=JKL33;9999481]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. END QUOTE

    You are correct, thanks for the clarification. Conscious sedation is not defined by the drug, but by the pt's response as to whether it's anxiolytic, moderate, deep or general anesthesia.

    CMS cited Vanderbilt for not having monitoring requirements (monitor for hypoventilation, for example) in their high alert medication policy, which included Versed.
  4. by   Susie2310
    Quote from JKL33
    CalicoKitty, these ^ examples are kinda scary in a way that would tell me I need to tighten up my practices. Let this be a reminder to remove/obtain medications conscientiously as if there were no scanning. That's the one surefire thing that would've prevented the error that is the subject of this discussion.

    Scanning should never be considered anything more than a double-check. There's no good excuse for making it to a patient's bedside with a med that is not the ordered med. Scanning is a process that should be merely confirming correct information that you already know.

    I understand what you mean when you say the case makes you glad for scanning, but I would suggest instead that we all should have the sh*t scared out of us the day that scanning actually prevents anything. Immediate personal corrective measures are indicated.
    Using the Five Rights for three checks before administering is a big part of preventing medication errors, as is having good knowledge of the medication, i.e., indications for giving, action, expected effects, side effects, contraindications, adverse effects and action to take, monitoring necessary, assessment before/after administering, pertinent lab values, precautions to take, etc. Barcode technology doesn't eliminate the need for these essential safety checks.
  5. by   Wuzzie
    Quote from Nurse Beth
    CMS cited Vanderbilt for not having monitoring requirements (monitor for hypoventilation, for example) in their high alert medication policy, which included Versed.
    Although there is apparently evidence to support this citation I find it very difficult to believe that a tertiary center such as Vanderbilt would flaunt standards that even the smallest hospitals have had in place for years.

    Regardless of the lack of policy this nurse should have never administered a medication she was unfamiliar with. Anybody who has given this drug (Versed) knows it comes with a risk of hypoventilation and would monitor for it. If she had done the bare minimum for Versed the patient would not have died from the accidental Vecuronium. The cavalier choices she made (it starts with Ve, oh well close enough) should not be blamed on the hospital. Don't get me wrong I am a huge supporter of not blaming nurses for system failures and human error but this goes waaaayyyy beyond that. Frankly, calling this a "mistake" is a misnomer. She made bad, bad, inexcusable choices that resulted in the death of another human. I'm sure she's devastated. She should be. I understand the need for a non-punitive environment when it comes to med errors but jeebus we have to draw the line somewhere.
  6. by   Nurse Beth
    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 patient was doing well and what was ordered was a full body PET scan. I agree with several providers who questioned the necessity. Just provides the context and background decisions that led up to the event, which is helpful in an RCA. In outpatient, they probably would have given a po anxiolytic, not IV Versed. Of course the key factors are the nurse's actions and negligence.
  7. by   Horseshoe
    Horrible tragedy and mindblowing negligence by RN and puzzling lack of monitoring protocols to begin with, even if appropriate drug/dose given.

    And may I also add that KatieMi is a rock star.
  8. by   klone
    I have nothing to add, other than saying how humbled I am at how ******* smart my Allnurses colleagues are! You guys always keep me learning.
  9. by   blondy2061h
    I just got done reading the 56 page CMS report and I have a lot more questions than when I started.

    The nurse got the vecoronium out of the neuro ICU pyxis, where the patient was an inpatient. That explains how she had access to it. The bin was labelled as a paralytic that causes respiratory arrest.

    She's not sure how much she gave. Maybe 1ml or 1mg.

    She brought it down reconstituted in a baggie, gave it to the patient in a holding area. It was only when she gave the excess medication to the patient's primary nurse after the patient was brought back to ICU after the code that the primary nurse noticed it was vec.

    The patient was left with just the tech, unmonitored, in a room waiting to go into the scan. Never made it into the scan. This is a patient that came from an ICU and was step down status. These patients are always on monitor at my facility and are transported by an RN, not transport as described in the CMS report. Further in the report it says she was awaiting a floor bed, so that explains this.

    The RN was talking to the patient's family when she heard the code called in PET scan. She called PET scan not once but twice to see if it was her patient. She didn't get an answer. Calling an area during a code blue? How lacking in judgement is this person?

    She did indeed get fired.
  10. by   JKL33
    Quote from Wuzzie
    Don't get me wrong I am a huge supporter of not blaming nurses for system failures and human error but this goes waaaayyyy beyond that. Frankly, calling this a "mistake" is a misnomer. She made bad, bad, inexcusable choices that resulted in the death of another human. I'm sure she's devastated. She should be. I understand the need for a non-punitive environment when it comes to med errors but jeebus we have to draw the line somewhere.
    Understood.

    My thing, though, is that these things never occur in a vacuum - and that's not a cliche, it's still a fact and we have chosen to work very hard on some of the safety aspects of our environments while utterly ignoring, downplaying, and even covering up others. Someone has mentioned how much different this was than, say, giving an extra colace. I don't see it that way. The same things that contribute to errors that don't harm anyone contribute to errors that do cause harm. The difference is, if no one is harmed then no entity is publicly forced to correct anything and can get by with focusing on whatever fake fix-all they choose.

    If someone did this in my department I would cause a ruckus if no one was willing to talk about: 1) the incentivization of throughput 2) CAHPS/no one can wait 3) the roving/floating/help-all, never-quite-have-enough-help aspect 4) non-experts orienting others 5) contstant orienting 6) utter lack of concern and lack of agenda to effectively accomplish individual nurses' acquisition of expertise 7) literally constant "initiatives" that detract from the bottom line of taking safe care of people 8) technology being taught and advocated out of proportion with other essential concepts and practices, such as all the 5 rights and 3 checks we're all yapping about now. Right up until something baaaad happens, the name of the game is "move." The super fancy accomplishment-tracker EMR that V rolled out in the month before this incident is really good for producing great stats about employees' quick or slow performance.

    I feel as though safe practices are in the forefront of my mind. But carrying them out is to swim against the current 100% of the time.
    Last edit by JKL33 on Dec 2
  11. by   smf0903
    Quote from blondy2061h
    I just got done reading the 56 page CMS report and I have a lot more questions than when I started.

    The nurse got the vecoronium out of the neuro ICU pyxis, where the patient was an inpatient. That explains how she had access to it. The bin was labelled as a paralytic that causes respiratory arrest.

    She's not sure how much she gave. Maybe 1ml or 1mg.

    She brought it down reconstituted in a baggie, gave it to the patient in a holding area. It was only when she gave the excess medication to the patient's primary nurse after the patient was brought back to ICU after the code that the primary nurse noticed it was vec.

    The patient was left with just the tech, unmonitored, in a room waiting to go into the scan. Never made it into the scan. This is a patient that came from an ICU and was step down status. These patients are always on monitor at my facility and are transported by an RN, not transport as described in the CMS report. Further in the report it says she was awaiting a floor bed, so that explains this.

    The RN was talking to the patient's family when she heard the code called in PET scan. She called PET scan not once but twice to see if it was her patient. She didn't get an answer. Calling an area during a code blue? How lacking in judgement is this person?

    She did indeed get fired.
    According to the report they don't know how much she gave. Neither syringe was labeled as a med (again, according to report pages 35-36) and I could see it being entirely possible that the med was given as a flush and visa versa.
  12. by   Wuzzie
    Quote from blondy2061h
    I

    She's not sure how much she gave. Maybe 1ml or 1mg.

    She did indeed get fired.
    Fired? She's lucky she didn't get prosecuted. And I know I'm going to sound mean but I hope her license was taken away. You can't educate this kind of stupid.
  13. by   Wuzzie
    Quote from JKL33
    Understood.

    My thing, though, is that these things never occur in a vacuum - and that's not a cliche, it's still a fact and we have chosen to work very hard on some of the safety aspects of our environments while utterly ignoring, downplaying, and even covering up others. Someone has mentioned how much different this was than, say, giving an extra colace. I don't see it that way. The same things that contribute to errors that don't harm anyone contribute to errors that do cause harm. The difference is, if no one is harmed then no entity is publicly forced to correct anything and can get by with focusing on whatever fake fix-all they choose.

    If someone did this in my department I would cause a ruckus if no one was willing to talk about: 1) the incentivization of throughput 2) CAHPS/no one can wait 3) the roving/floating/help-all, never-quite-have-enough-help aspect 4) non-experts orienting others 5) contstant orienting 6) utter lack of concern and lack of agenda to effectively accomplish individual nurses' acquisition of expertise 7) literally constant "initiatives" that detract from the bottom line of taking safe care of people 8) technology being taught and advocated out of proportion with other essential concepts and practices, such as all the 5 rights and 3 checks we're all yapping about now. Right up until something baaaad happens, the name of the game is "move." The super fancy accomplishment-tracker EMR that V rolled out in the month before this incident is really good for producing great stats about employees' quick or slow performance.

    I feel as though safe practices are in the forefront of my mind. But carrying them out is to swim against the current 100% of the time.
    The thing is she willfully violated Every. Single. Safety practice that was set in place. Even the most basic (5 rights) precautions that a first year nursing student had drilled into their heads. She can't even remember how much of the med she gave? 1 ml or 1mg? Mixed up generic and trade names and grabbed the first thing that sorta matched? Failed to monitor for response to the medication she thought she gave? Unlabeled syringes? Clearly was unfamiliar with Versed? Administered it in the waiting room? Left an ICU patient unattended? I just don't see how the system failed this nurse. This nurse failed the patient.

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