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Nurse Gives Lethal Dose of Vecuronium Instead of Versed

Nurses Article   (234,856 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.

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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 12 of Nurse Gives Lethal Dose of Vecuronium Instead of Versed. If you want to start from the beginning Go to First Page.

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This is what I was saying earlier. Compare--

versed vecuronium

midazolam vecuronium

and ask if that same mistake would have been made.

And hope midodrine isn't available/on formulary when overriding/picking meds for head bleed patient.

***

If you don't "select for" critical thinking and conscientiousness, you won't get it. If you don't expect it, encourage it, incentivize it, hire for it, pay for it, and support it, you won't get it. If you work against it, you definitely won't get it. Bottom line.

***

I'm not sure that follows through as cleanly as they think, anyway. Few people seem to even register things like tartrate vs. succinate, and pharmacy themselves have sent the opposite of each ordered form of these salts/meds and then when called to tell them the error, they advised overriding it if it wouldn't scan. In one incident of world's best EMR roll-out, another "why won't this med scan" arose because the person was holding methylprednisolone acetate when what was ordered was methylp sodium succinate, and even on the administration screen the error wasn't obvious because you would've needed to click on something to see the full name of the med that had been ordered. Any idea how easy it would've been to say just override it and we'll file another one of a thousand other "tickets" being filed during this process?

Granted, it wouldn't have produced a fatal error, but various needs for overrides (or erroneous needs not recognized as such because "real" needs) for overrides aren't as rare as what the media hype of this case would suggest. That's why it's slightly sleazy for V to speak of the override function as if it were a completely off the rails act in and of itself. Don't forget they were within just over a month of having "rolled out" their billion-dollar data generator, and in fact somewhere in the report it's mentioned that the nurse made no effort to document the (Versed) because she was told by a manager something to the effect that the new system would "capture it" because she had removed it from pyxis. This is the kind of multi-faceted, run-of-the-mill dysfunction we're talking about. Day after day after day. Multiply it by a gazillion if you're still in the thick or the aftermath of one of these roll-outs.

Trade names are heavily advertised as everyone knows. Patients come in with mixed lists; they speak of their meds both ways depending on which particular preparation they happen to take. I think you should know (or have time to figure out) "Revatio" on someone's list when you're about to give the first 400 of 1200 mcg of nitro. I also think the people who are allowed to "get my RN" and certainly whichever ones of those are hired for the care of sick patients, should be those who are able to process the idea that medications might have two names.

A corporate entity is in control - they get exactly what they plan for, hire for, pay for, incentivize, and demand. They have spent a lot of money and effort telling conscientious people they're stupid and their attempts at critical thinking just kill big jetliners full of people and lead to disaster, which is why we need things like barcode scanning in order to "decrease those situations where you need to use critical thinking"[direct quote]. "We don't want to put you in that position." [Direct quote]. That probably wasn't a wise way to attempt to get staff buy-in for new technology.

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Which is why technology needs to be the last line of defense, not the first.

Exactly. And why rigorous nursing education and training as knowledge work should be the first line of defense. This task-monkey orientation to nursing practice is the greatest threat to patient safety there is.

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Cococure has 7 years experience and works as a RN on a mother/baby unit.

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Great post. I represented a nurse who was floated to the ER. She never worked there and had no experience. She expressed her concern but management insisted she go. A similar mistake happened but fortunately, the patient did not die. No wonder why there are over 100,000 unnecessary deaths in hospitals each year. Nurses are overworked and are bombarded with new information every few minutes.

THANK YOU, THANK YOU!! For making this statement, it is crazy how we are expected to float and work anywhere because we are RN's. Mgmt is quick to say patient abandonment if you are not a ''team player''. Yes, nurses are overworked and unreasonable expectations placed on us. I am not excusing the major mistakes she made but she obviously not from that unit and unfamiliar with the med. and it played a role...that issue needs to be addressed.

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I am not excusing the major mistakes she made but she obviously not from that unit and unfamiliar with the med. and it played a role...that issue needs to be addressed.

She. Should. Have. Said. Something.

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Daisy4RN has 20 years experience.

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That is what I've been saying all along. Who the heck gives an IV push medication in THE WAITING ROOM and then just walks away. I don't care how busy you are, you stay and assess your patient. It doesn't matter what drug you're pushing. If there is going to be an adverse reaction it's going to happen fairly rapidly.

Exactly! When I worked med-surg we (at times) were required to go to CT etc and give meds bc pt was anxious. Even when it was Ativan (even small doses) we were required to stay with the pt.

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Daisy4RN has 20 years experience.

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Exactly. And why rigorous nursing education and training as knowledge work should be the first line of defense. This task-monkey orientation to nursing practice is the greatest threat to patient safety there is.

I agree that to help prevent errors the tech and system should be address. When I started nursing all patients meds were in a drawer in the pt room (no pyxis). We were taught/trained to read, think, read the labels and be careful. I think sometimes people just rely on the tech and don't think for themselves. Also, I wonder why this nurse was running off to ER for a swallow test, where was SP therapy, why so urgent, I can just see a upset screaming pt in ED who is not being allowed to eat taking precedence over the safety of this pt, (supervisor calling and hurrying nurse to get to ER for customer service?) The nurse should have known but system still should be looked at.

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MunoRN has 10 years experience and works as a Critical Care.

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Since there was no job description for the "help all nurse", no competencies were established for the role. I'm sure creating a job description will be at the top of Vanderbilt's corrective plan of action.

Job descriptions don't establish the required competencies, usually the job description will be for the job of "Registered Nurse", and will state that the nurse will 'maintain competencies as assigned'. A job description is not easy to change during someone's employment, yet what competencies a nurse might need to have does change over time, which is why they are kept separate.

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Double-Helix has 6 years experience and works as a Nurse, Children's Hospital.

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If the order was reviewed by pharmacy, why was it not profiled? This would have eliminated the need for an override.

The article says that the nurse couldn't find "Versed" (brand name) in the Pyxis. So she tried to search for it using "VE" (again, implies she was looking for the brand name.

My assumption is that the nurse didn't realize that the medication would be profiled under the generic name, "midazolam."

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This was Vanderbilt? It's only one of the top teaching hospitals in the country! As the article states, there is no defense for this. It's a simple matter of how many "zeros" to put on the check they're going to have to write.

Wow. Unbelievable.

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The nurse who administered it did not even document it. Hard for the system to have checks and balances when the system is bypassed.

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Job descriptions don't establish the required competencies, usually the job description will be for the job of "Registered Nurse", and will state that the nurse will 'maintain competencies as assigned'. A job description is not easy to change during someone's employment, yet what competencies a nurse might need to have does change over time, which is why they are kept separate.

Very salient point Muno. And given the very basic nature of the nursing process that this nurse violated multiple times one would think that any RN could have completed the task without the patient ending up dead. What is needed is not a job description but job requirements. Things like a certain amount of experience with emphasis on breadth as much as length. But even more important would be critical thinking skills and leadership. Unfortunately the latter are not quantifiable. And one quality that is often overlooked and frequently scorned-the ability to stand up for one's self and the patients and say "no, I can't do that". And mean it.

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

I think the John Hopkins article which you can google: "John Hopkins study suggests medical errors are third leading cause of death in US," gives a good explanation of what happens re the CDC.

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