Jump to content
2019 Nursing Salary Survey Read more... ×

Nurse Gives Lethal Dose of Vecuronium Instead of Versed

Nurses Article   (234,994 Views 360 Comments 1,069 Words)
by Nurse Beth Nurse Beth, MSN (Advice Column) Writer Innovator Expert

Nurse Beth has 30 years experience as a MSN and works as a Nursing Professional Development Specialist.

337 Likes; 10 Followers; 81 Articles; 224,817 Visitors; 1,689 Posts

advertisement

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. You are reading page 10 of Nurse Gives Lethal Dose of Vecuronium Instead of Versed. If you want to start from the beginning Go to First Page.

blondy2061h has 9 years experience as a MSN, RN and works as a Nurse, duh!.

3 Likes; 37,031 Visitors; 4,094 Posts

Wow, what a terrible mistake and breakdown in safety protocols. I can't imagine being responsible for someone's death. That would haunt me for the rest of my life. I would never even want to be a nurse again. This nurse will never be the same, that patients face will be with her for the rest of her life.

Oh I do suspect she'll never be a nurse again

Share this post


Link to post
Share on other sites

blondy2061h has 9 years experience as a MSN, RN and works as a Nurse, duh!.

3 Likes; 37,031 Visitors; 4,094 Posts

I work in radiology and sedate patients every day, our hospital has a scanning system but we don't scan any of our meds, the patient is either covered or inside the scanner, the meds aren't ordered ahead of time so they aren't on the patient's profile, except in this case because the doctor is scrubbed in and gives verbals during the case, the time-out is the patient check, since we do anesthesia cases also our Pyxis has paralytics in it and all our meds have to be an override, if you are not trained or in too big of a hurry, i can see how you could grab the wrong vial, i've written several safety reports because the wrong meds were in drawers or because the way the pyxis was loaded made it too easy to grab the wrong thing (you have to pull it out the whole way to get zofran if you only pull it out halfway you get amlodipine)

I agree the nurse was negligent, but blaming her won't save anyone's life. Learning from this can.

-Don't give meds you aren't familiar with, if you aren't sure look them up. In a genuine emergency someone else will be there to ask

-If you aren't trained in an area or aren't comfortable in a task refuse the task no matter how pressured you may feel

-No ICU patient should be out of the ICU without an ICU nurse or an anesthesiologist assuming care. If the nurse covering for lunch wasn't an ICU nurse or sedation nurse either lunch break has to wait, the scan has to wait, or someone else needs to take them

-No ICU patient should be on any table or in any scanner without monitoring and a nurse monitoring them

-If a patient is sedated for a scan or procedure (even if all you gave them was 0.5 of Versed) they have to be monitored for the duration of the scan ICU or not

-Know what resources your hospital can pull out of a hat, I've call my house supervisor after hours because the patient's ICU nurse had to leave since his other patient was coding upstairs leaving me alone with a patient that had unstable pressures, needed drips titrated and I had already started sedating. She sent me a rapid response nurse to manage the drips so I could focus on the sedation

I was initially confused at how an ICU patient ended up off the unit without an ICU nurse or monitor, but it seems the patient was awaiting a floor bed.

That then makes me confused why they jumped to IV versed for a PET scan. Seems like PO Xanax would have been a more appropriate starting point, but obviously I don't know the patient.

Share this post


Link to post
Share on other sites

blondy2061h has 9 years experience as a MSN, RN and works as a Nurse, duh!.

3 Likes; 37,031 Visitors; 4,094 Posts

She only gave 2 mg of Vec, they have the rest of the med in the syringe, which is a very small dose.

They don't know how much was given. The CMS report makes that very clear. There were two syringes with different amounts of liquid. They weren't able to determine what was in each one.

The nurse was very non-committal to what dose she gave. To me that means she really was totally clueless or she was being dodgy. I get that this happened a year ago, but I made a serious med error 7 years ago and remember everything about it.

Share this post


Link to post
Share on other sites

blondy2061h has 9 years experience as a MSN, RN and works as a Nurse, duh!.

3 Likes; 37,031 Visitors; 4,094 Posts

Could have overrided and pulled verapamil and we'd never, ever heard of this...so close...if only 'r' came before 'c'....

It's a good point. A nurse I work with made an extremely similar error, but the med they gave instead of the ordered med was not one with life threatening side effects so no viral news story there.

Share this post


Link to post
Share on other sites

NuGuyNurse2b works as a Student Nurse.

22 Likes; 9,117 Visitors; 922 Posts

But if the option is a nurse with no ER experience or no extra nurse at all, I'll take the one with no ER experience. I won't expect them to function independently, but they can be delegated to by other nurses. Hopefully there are some tasks they know how to safely do- drawing labs, starting IVs, taking vitals, hanging IV antibiotics, giving pills, helping transport people, etc.

That's just simply not a realistic expectation for the ED. If the ED is short a nurse the ED needs an ED nurse to handle the patient load, not a "runner" floor nurse who would "help" an ED nurse because regardless of what extra help that floor nurse does, the ED nurse is ultimately responsible for those patients since that floor nurse cannot be independent. Instead of getting an additional ED nurse to split the assignment, getting a helper nurse to do tasks will not benefit anyone. That is why the nurse who protested getting sent to the ED was within her rights to do so. It's also why (safe) ED's go on divert mode when there's staffing issues instead of plucking from the float pool or pulling from any of the other med surg floors because their level of training and education are not the same as the skillset required of an ED nurse.

I'll give you an example - when I worked med surg, we did not draw labs - phlebotomy did that. If I had been floated down to the ED, I wouldn't have been able to "help" the ED nurse with that. Furthermore, my med surg mindset would go looking for a pump to hang IV antibiotics, never knowing that in the ED, with the exception of Vanco, everything is hung by gravity. if someone told me to go get "Bair Hugger" I wouldn't even know where to begin cause I wouldn't even know what it was since we don't use it on the floor. And would you really expect a floor nurse, who goes to work every day to the same floor, know where MRI/CT scan/XR/etc are to even transport patients? So the assumption that a nurse is a nurse is a nurse is not safe, and downright wrong, even if it's just as a helper nurse to a specialized floor, which the ED is. And that's pretty much what happened in this case with the Versed. That nurse who gave it had no idea what she was giving. And she too was "helping".

Share this post


Link to post
Share on other sites

2 Likes; 3,160 Visitors; 380 Posts

Even as a nursing student, I knew the difference between vecuronium and versed!!! This nurse was beyond negligent and should have her license taken away and involuntary manslaughter charges should be pressed. This is unacceptable practice that resulted in a horrifying death for a patient that should never, ever have happened! I am sickened by this.

It was a horrible event and the nurse screwed up, but I can guarantee you that every error made is from not doing checks or having a momentary lapse of judgment. You will make errors, which may or may not have severe consequences. Your level of anger towards this incident makes me feel uncomfortable, and I hope when you make a mistake, you are treated in a kinder fashion.

Edited by Triddin

Share this post


Link to post
Share on other sites

Pixie.RN has 18 years experience as a MSN, RN, EMT-P and works as a Infection Preventionist/Nurse Epidemiologist.

252 Likes; 7 Followers; 32 Articles; 125,608 Visitors; 12,817 Posts

Furthermore, my med surg mindset would go looking for a pump to hang IV antibiotics, never knowing that in the ED, with the exception of Vanco, everything is hung by gravity.

What? Seriously?

Share this post


Link to post
Share on other sites

Axgrinder works as a RN.

3 Likes; 5,542 Visitors; 256 Posts

Under different circumstances this could have happened to any one of us. Not to say I wouldn't read a label or a box, but being stressed due to extreme pressure to hurry because tasks are piling up makes it more likely that mistakes will happen. In a hectic work environment with more patients than is safe, or coming into brief contact with patient's you are unfamiliar with, I most definitely can imagine a situation where you thought you had one drug but it turned out instead to be one that was very different than the one you intended.

I've never done float nursing where I roamed all over a facility helping out where needed, but a position such as that would seem to require a vast amount of experience in very different types of nursing to competently be qualified for that type of job. It would take a very special nurse to do that job well.

My heart breaks for the patient who thought she was in safe hands, and for the nurse who made such a grave error. I can't even imagine what she or he is going through.

Share this post


Link to post
Share on other sites

KatieMI has 6 years experience as a BSN, MSN and works as a Internal Medicine.

207 Likes; 40,747 Visitors; 2,321 Posts

I was initially confused at how an ICU patient ended up off the unit without an ICU nurse or monitor, but it seems the patient was awaiting a floor bed.

That then makes me confused why they jumped to IV versed for a PET scan. Seems like PO Xanax would have been a more appropriate starting point, but obviously I don't know the patient.

Bing, bing, bing! Beeper goes on...

Hi, doctor Jones! This is Mary, nurse from XX. I take care of the lady from ###. She is on hold transfer from ICU to Floor, just waiting for her PET to be done... no, she is still down there... no, they will do the PET... I just wanted to touch base with you regarfing this patient, I just wanted to let you know that she is just SOOOO anxious, she is restless, I saw her crying, she is SOOO afraid, she told me she can be clautrophobic... Family is very concerned and they are not happy with our care... I justtryingtodomyjobandjustwanttoletyouknowaboutmyconcerns... CAN SHE JUST HAVE SOMETHING TO JUST HELP HER RELAX FOR A LITTLE?

Something tells me it very well could look like that.

If physician placed "range order" (see the document - not "2 mg IVPB time 1" but playing with 1 to 2 mg here and there), it likely means that he/she had concerns about this order. "Range orders are not usually welcome as they are obviously more dangerous. If he/she placed it that way, there got to be a reason for that.

And it is another story why "anxiety" or even touch of thinking about it suddenly became something we need to "medicate" right away. If someone just could stay with the patient and entertain her for an hour, it is likely would be enough for alleviating her anxiety.

Edited by KatieMI

Share this post


Link to post
Share on other sites

aprilmoss has 20 years experience and works as a School Nurse.

54 Likes; 1,656 Visitors; 225 Posts

Even if you don't have a grip on the pharmacology, it was drilled into us early on to CAREFULLY READ THE VIALS (or whatever). They would slip in a vial of Ephedrine during practice that called for preparing Epinephrine. That's a real easy one to miss if you've not got a professional attitude. Close spelling doesn't count.

Share this post


Link to post
Share on other sites

Hematocrit13 works as a Nurse.

5 Likes; 1,324 Visitors; 43 Posts

And medical errors are not reported on patients' death certificates.

Is that why it's not tracked by the CDC?

Share this post


Link to post
Share on other sites

4 Likes; 23,353 Visitors; 3,726 Posts

Anyone else wondering about the girl in the stock photo? Probably not.

I was thinking that I would not want my photo associated with this story.

Share this post


Link to post
Share on other sites
×