Nurse Gives Lethal Dose of Vecuronium Instead of Versed

  1. On December 26, 2017, a tragic and preventable death occurred when a patient at Vanderbilt Hospital was sent for a Positron Emission Tomography (PET) scan and received a lethal dose of Vecuronium instead of Versed.

    Nurse Gives Lethal Dose of Vecuronium Instead of Versed

    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 utilization.

    If it had been done in the outpatient setting, it's unlikely that Versed would have been administered. Essentially a patient died because a dangerous medication that was never ordered was given.

    The patient, a 75 yr old female, was admitted to neuro ICU on 12/24/2017 with intraparenchymal hematoma of the brain, headache, homonymous hemianopia (loss of visual field bilaterally), atrial fib, and hypertension. She was alert and oriented and doing well, about to be transferred to SDU. While the patient was waiting for her scan, she asked for medication to prevent claustrophobia. The provider ordered 2 mg of Versed, and the pt's nurse was asked to come down and administer it.

    At the time, the pt's nurse was covering a lunch break for another nurse and asked the "help all nurse" to go down and give the Versed so the procedure would not be delayed or rescheduled. The "help all nurse" performs different tasks, but there was no job description for a "help all nurse". It is not clear if the "help all nurse" was an ICU nurse, or a nurse floated from elsewhere, such as Med Surg. Clearly, the "help all nurse" was not trained in conscious sedation, and was seemingly unfamiliar with both Versed and Vecuronium.

    The "help all nurse" searched for Versed under the pt's profile in the Pyxis but it did not come up. So she chose override and typed in "VE". The first drug to come up was Vecuronium, which she selected. She then proceeded to reconstitute the drug, not recognizing that Versed does not need to be reconstituted, and not taking heed of the red cap on the vial or the words "paralytic agent". Next, she administered 2 mg of the Vecuronium IVP and left the patient.

    Vecuronium and Versed

    Vecuronium is a neuromuscular blocking agent that causes paralysis and death if patients are not monitored.
    Basically, the patient will be paralyzed, conscious and unable to draw a breath. All sensation will be experienced- panic, pain, fear, but the patient is unable to cry out. It's truly the stuff of nightmares.
    Versed is often given for procedural sedation but is not a paralytic. Versed can affect respirations, and patients must be closely monitored for hypoventilation.

    Timeline

    Here is a timeline of events, where the time was documented.

    • The doctor ordered Versed 2 mg IV at 1447 on 12/26/2017.
    • The Pharmacy reviewed the order at 1449.
    • Vecuronium 10 mg was withdrawn from the Pyxis at 1459 using override.
    • Vecuronium administered but not documented. Patient left alone, unmonitored.
    • Rapid response was called at 1529.
    • Return of spontaneous circulation (ROSC) was restored after 2 rounds of ACLS
    • Patient was intubated and returned to neuro ICU
    • Patient displayed myoclonic jerks with posturing in ICU
    • Anoxic brain injury is documented
    • Extubation was performed at 1257 on 12/27/2017
    • Death was pronounced at 1307 due to pulselessness

    The Findings

    The Department of Health and Human Services Centers for Medicare and Medicaid (CMS) did not investigate the event until October, 2018 as the death was not reported to them at the time.
    According to CMS standards, patients have a right to receive care in a safe setting and hospitals have a responsibility to mitigate potentially fatal mistakes.

    CMS ruled that Vanderbilt failed to provide safe care and protect patients. Vanderbilt was placed in serious and immediate jeopardy by CMS.

    Since that ruling, the CMS has accepted Vanderbilt's plan of action.

    What Went Wrong


    • No documentation of the Vecuronium being administered
    • Patient was not monitored
    • Autopsy was not conducted as should have been for an unusual death such as one caused by a medication error
    • Death certificate said the cause of death was a cerebral bleed, not a medication error.

    Contributing Factors

    • Pyxis override functionality - a necessary function, but contributed to the error
    • Failure of the hospital to ensure that only nurses trained in conscious sedation can administer Versed
    • Failure of hospital policy to address the manner and frequency of monitoring
    • Concern about convenience over safety- pressure to not reschedule a test rather than taking the time to safely prepare the patient
    • Staffing- Covering another nurse's patients results in an unsafe workload

    Blaming

    The simplest thing is to blame the nurse for 100% of the error. Her failure to follow basic medication safety steps is not defensible.

    But stopping there prevents us from learning how it happened and preventing future mistakes. We need to learn more about the science of mistakes. We all make them. Something in our brains allows us to see what we expect to see and not always what is there, as in running a red light. Or not registering red caps and cautionary labels on a high-alert medication.

    The "help all nurse" was distracted in that she had an orientee with her, and immediately after giving the medication, went to the ED to perform a swallow screen test. She was performing a series of tasks.

    The patient's nurse did not delegate appropriately as she did not confirm the "help all nurses " knowledge and skills. Tasks should be delegated to the right person, and this was not the right nurse to administer Versed. Maybe nurses are not all interchangeable as administrations sometimes like to think.

    Vanderbilt did not clearly define role expectations, or patient monitoring in conscious sedation.

    What do you think were the causes, and would have prevented this from occurring?

    Related post When Nurses Make Fatal Mistakes

    Best wishes,

    Nurse Beth

    Author, "Your Last Nursing Class: How to Land Your First Nursing Job"...and your next!
    Last edit by Nurse Beth on Dec 2
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    314 Comments

  3. by   traumaRUs
    What a series of errors that caused this. The first was the lack of knowledge by the nurse in knowing the difference between versed and vecuronium. If she had an orientee with her, thats two nurses that should have known the difference between these two drugs. The nurse should have remained in the room with the pt with a monitor, pulse oximetry and immediate access to resuscitative equipment as well as being certified to administer conscious sedation.

    Then, we get to the Pyxis override, the pharmacy, the provider themselves who ordered the sedation.
  4. by   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?
  5. by   Daisy4RN
    I cannot even imagine the horror that the patient must have went through!!
    The nurse should have known what her role as "help all nurse" entailed. I have worked as a resource nurse and knew it was my responsibility to know not only the role, but also, as any nurse should know, my personal limitations including the meds you are giving. Although I will say that when there are too many warning labels on everything they do tend to get overlooked. The nurse was (obviously?) just running from one task to the next which can be even more hectic than having your own patients and you dont always have the full picture. Although it sounds like there is plenty of blame to go around at this facility regarding this situation.
  6. by   Luckyyou
    I'm sure that the nurse was rushed or distracted and many factors lined up to cause this error but...

    Every dose of every paralytic I've ever given came out of a vial with very large "PARALYZING AGENT" on the top, side, and lid of the vial, as well as a distinct neon yellow color on the labels.
  7. by   canoehead
    I wonder how long she had been a nurse. If she was running around trying to please everyone, or if she had a year or two experience. The more I hear about it, the nurse was inexcusably negligent, but there are certainly a lot of ideas for improvement within the system too.

    Imagine grabbing a med, Versed, not finding it, then going V-E- "ah, close enough!" Let alone not looking up either one. Good grief.
  8. by   KatieMI
    No job description for someone who holds the job? Really? In USA, 2017?? In a large academic hospital???

    Nurse working in ICU (although without job description - see above) has no idea about drugs used in ICU pretty much all the time (well, maybe not vecuronium, but Versed??) She never even hold a bottle of Versed so that not to know that it is not reconstituted? Vec also is in really special bottles, they look like nothing else...??

    ICU level patient left "alone and unmonitored" for 30 min. She is not hooked to transport monitor, there is absolutely no sensors (in imaging suite within a large academic center), there is no ACLS certified staff member from ICU who took her there. She was laying absolutely motionless on PET table (30 min is just about right time for the scan) and no one noted she was not moving?

    "Lethal" (loading) dose of vec is 0.08 - 0.1 mg/kg. The bottle normally holds 10 mg - enough for one IV push load for patient weighting 70 to 100 kg. 2 mg would cause weakness which could, in turn, cause respiratory acidosis and secondary arrest, more likely on an already weakened patient with not much muscles to begin with. But it still doesn't make it "lethal".

    PET scan suite, within the hospital walls, apparently run by... no one? Techs alone? No one to monitor the patient? No one yelled their constant "how are you doin' there?? Almost done, just a second more!" No one paid attention to lack of movement artifacts???

    Pixes program allows simple overwrite for everything as long as it starts with the same letters? Dilaudud = dilantin = diazepam = diclofenac? I wanna work with such a miracle box!

    Either things in Vanderbilt are run by a group of recent Acute Psych unit escapees, or I do not know.
    Last edit by KatieMI on Dec 1
  9. by   murseman24
    Quote from KatieMI
    No job description for someone who holds the job? Really? In USA, 2017?? In a large academic hospital???

    Nurse working in ICU (although without job description - see above) has no idea about drugs used in ICU pretty much all the time (well, maybe not vecuronium, but Versed??) She never even hold a bottle of Versed so that not to know that it is not reconstituted? Vec also is in really special bottles, they look like nothing else...??

    ICU level patient left "alone and unmonitored" for 30 min. She is not hooked to transport monitor, there is absolutely no sensors (in imaging suite within a large academic center), there is no ACLS certified staff member from ICU who took her there. She was laying absolutely motionless on PET table (30 min is just about right time for the scan) and no one noted she was not moving?

    "Lethal" (loading) dose of vec is 0.08 - 0.1 mg/kg. The bottle normally holds 10 mg - enough for one IV push load for patient weighting 70 to 100 kg. 2 mg would cause weakness which could, in turn, cause respiratory acidosis and secondary arrest, more likely on an already weakened patient with not much muscles to begin with. But it still doesn't make it "lethal".

    PET scan suite, within the hospital walls, apparently run by... no one? Techs alone? No one to monitor the patient? No one yelled their constant "how are you doin' there?? Almost done, just a second more!" No one paid attention to lack of movement artifacts???

    Pixes program allows simple overwrite for everything as long as it starts with the same letters? Dilaudud = dilantin = diazepam = diclofenac? I wanna work with such a miracle box!

    Either things in Vanderbilt are run by a group of recent Acute Psych unit escapees, or I do not know.
    THIS. She went through the trouble of reconstituting it and everything, come on. You know she just gave the whole vial.
  10. by   applewhitern
    I work in ICU and we no longer have paralytics in our medicine dispense system. We can only get it from pharmacy or ER. This really bewildered me when I first started working at this hospital, but now I can see why! One would think any nurse would know the difference, but apparently not. We avoid this type of error by simply not having it available in the pyxis, and also, only a physician is allowed to administer a paralytic at this facility. Yes, it is a pain in the rear for the nurses, but it helps avoid this type of mistake.
  11. by   ponymom
    This is a bit above my nursing experience, but I am just heartsick and astounded over this whole tragedy.
  12. by   KatieMI
    BTW, another, and seriously strange thing:

    Patient was getting, as far as I understand, PET brain scan. PET is super-functional and super-acute thing as related to brain. It is possible to tell if a person thinking intensely or just relaxed and daydreaming during it. So, someone trying to tell that a human being, apparenly not comatose, was laying there acutely paralyzed and experiencing extreme anxiety (no doubts of it, as she was able to experience claustrophobia and then she was there slowly suffocating) and PET pic was not getting kinda very strange?

    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.

    I really would like to know also what the heck they wanted to see or find on autopsy. Death by non-depolarizing agent, especially in low dose, must leave virtually no trace after T 1/2 (30 min for vec) × at least 12. Vec is normally reversible spontaneously by tissue anticholinesterases, so thin layer chtomatography for both vec and metabolite would likely be negative after that long. Otherwise, death from vec looks precisely like any other death from hypoxia inflicted by non-traumatic cause and nothing more.

    https://www.google.com/url?sa=t&sour...Vj2x6wIJoKIKsv
    Last edit by KatieMI on Dec 1
  13. by   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.
  14. by   twinsmom788
    "Either things in Vanderbilt are run by a group of recent Acute Psych unit escapees, or I do not know."

    "Or I do not know" That is correct. You don't know. Trust me, Vandy is run by a expert and knowledgeable group of physicians and nurses. My daughters have both worked there in the summer between their third and fourth year of med school.

    I have some knowledge of this hospital because I have been there numerous times to investigate sentinel events very much like this. There are mistakes made at this very large hospital complex and I have substantiated several of them.

    Please read the 2567 to obtain more details so you will know.

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