Nurse Gives Lethal Dose of Vecuronium Instead of Versed

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.

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

Fair enough, but most of my posts are not really meant to assign blame, but perhaps widen the discussion some. Again, there's no question this nurse should lose his/her job. But is there anything else to talk about besides that? The answer seems to be yes. At least to me. Because, again, there's still a lot we don't know, and I read the report.

I think pointing out the incredibly stupid actions of the nurse is important to discuss if it helps even one person here really scrutinize their nursing practice. Perhaps by not giving this nurse a pass we can save a life. Look, I'm human like everyone else and I'm sometimes tempted to take shortcuts to make my life easier. What I do to curb that temptation is ask myself would I be okay with a nurse doing this to one of my loved ones. It draws me up short and helps me keep my priorities straight. I also understand the importance of non-punitive environments in order to keep the avenues to education open but we do have to draw the line somewhere. This wasn't an oopsie I gave ASA 325 instead of 81. In addition I think we have a responsibility to the students and new nurses here to continue to instill in them the importance of the basics. After all it was a lack of attention to the basics that killed this patient.

FTR. I read the full report too. The override is clearly documented by the Pyxis system so there's no doubt it happened. We have the exact times even. I think the report gives a pretty clear description of the sequence of events. The only thing not definitively answered is exactly how much Vec the patient received.

Specializes in ED, ICU, Prehospital.
Fair enough, but most of my posts are not really meant to assign blame, but perhaps widen the discussion some. Again, there's no question this nurse should lose his/her job. But is there anything else to talk about besides that? The answer seems to be yes. At least to me. Because, again, there's still a lot we don't know, and I read the report.

And, again, I suggested that Vanderbilt's staff be re-evaluated. The way they do things from A to Z. Screening and requirements for oncoming RNs, onboarding requirements, unit orientation, role responsibilities---oh, you know---actually having a JOB DESCRIPTION for that "whateveritwas" that we all call a "FLOAT" in other hospitals?

It really chapped my hide that Vanderbilt covered it up and is only now admitting to some of it. A year later. The culture there seems to enable this sort of lax behavior.

An ICU Charge RN sent this float with a student and a syringe of versed to dose this patient and come back. What kind of training, or lack thereof, made it okay for this Charge to send this RN down there under these circumstances? Or did the RN not have the permission to leave the floor, which speaks volumes of the unit itself.

My Charge knows precisely when we are doing anything off the unit, on behalf of the unit. At all times. It's her job..

Others commenting here are correct. It's the culture at Vanderbilt that needs examining. Why did this RN feel it was okay to do ANYTHING she did? It was a series of bad decisions. This could not have been isolated and to just this one RN.

I came from a "Wild West" attitude department. My RN Mgr and Charges didn't care what we did, as long as the job got done. I'd saw an RN leave on his motorcycle in the middle of a shift to go to a restaurant across town because he just couldn't stand hospital food anymore---and didn't tell a soul. Just left his patients, knowing that with the chaos of such a large Level 1, it would probably take time to figure out he had been off campus for over an hour.

There are those in units that are allowed to get away with whatever they like, making decisions that are outside their scope, because they are permitted to do it.

JKL, you made a great point---why is ANY RN permitted to keep their license after this type of mistake and the key word here was "negligent". This RN was NEGLIGENT. The definition of negligence in medicine is doing (or not doing) something that any normal RN in that circumstance would (or would not) do.

Vanderbilt screened, hired, trained and staffed this RN. She didn't just come from the clouds and this magically happened. Vanderbilt will never open their books to show the number or the seriousness of their staffing mistakes, their numbers, their culture. It would be a lawyer's wet dream.

I know my old place of employment should be turned upside down and shaken by the ankles really hard---shine some light on the practices of a so called magnet status level 1. People would be appalled and horrified at some of the things that go on. The hospitals cover these things up because as long as they can bill and be reimbursed, and they can keep the lawsuits private, they go on business as usual.

It is this RNs fault, and she should, at the very least, be stripped of her license. She proved that she can't even maintain the minimal safety standards.

Honestly, Hematocrit, the issue here is the egregious behavior of that RN and the lesson that we all need to be reminded of---patient safety is the reason we do what we do. Vanderbilt isn't going to change, because this facility is a carbon copy of pretty much every other facility like it---where profit is placed above all else.

The only thing that changes places like that is a huge scandal that dents their bottom line to the point they cannot ignore it further. KPH had so many falls and it cost them so much money in lawsuits---not because of lack of training for RNs, but because their facilities SUCK. They are littered with crap all through the halls, there is no room to work, no room for equipment...just shoving patients in every square inch of space they could....to make that money.

When the lawsuits tallied up to X amount---there were crap-tons of resource available for falls risk. PACKETS. Special socks, arm bands, magnets for the door, a whole sheet you had to fill out q1hr to prove you were watching that pt at all times, the secretary had to have a special notification, stickers for the outside of the gown, a YELLOW BLANKET....it was crazy. The amount of money spent on just that alone---and all they had to do was clear out the damned CLUTTER.

But no. Too easy. Make it an additional burden on RNs and staffers. Make it the responsibility of already overwhelmed staff...and STILL make them do a slalom course to just get one wheelchair to CT.

There is enough blame to go between the RN who did this infusion and Vanderbilt's staff and culture. She'll get the brunt of it, because she is not qualified to do this job with such a lack of decision making skills. Vanderbilt, however, is the one that screened, hired, oriented, trained and placed her. SOMEONE along the way must have noticed---and if they didn't....that needs to be looked at very closely.

Specializes in Mental Health, Gerontology, Palliative.
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

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.

I recall having a very pushy ward clerk who was demanding my time while I was attempting to second check IV medications with another nurse. I politely said "I need to finish this. Give me three minutes and I will come and talk to you"

Finished the check, went to find the ward clerk who advised that the matter had been dealt with.

I'll always keep it polite, no one interrupts me when I'm doing meds (only exception would be life threatening events) and I'd start the whole thing again if need to afterwards

We should never be afraid to say to someone "you will need to wait until I finish X"

Its all about safe nursing care

Specializes in ICU, LTACH, Internal Medicine.
I want to know why versed was ordered in the first place??? Ativan would have been plenty

Because when you respond to one of these hysterical calls about "patient needing something for something RIGHT AWAY", the impression you get is that the patient is about to go psychotic out of anxiety or suffer some other really serious harm. The doctor likely had no idea about keeping the patient in pre-test room for full 60 min. It takes some experience, time and luck to determine what is STAT and what is nothing in such situation.

I seriously got calls asking for "something for bowel movement" so to prevent... not mundane constipation, but ileus and SBO. Or "something for secretions" to prevent aspiration on A, Ox4 otherwise more able bodied than myself walkie/talkie. These "rationales" made it in daily nursing notes.

Again, imagining yourself a kind of all-hovering guardian angel is not an evidence of one "justdoingmyjobasanurse". It is an evidence of being poor fit for just such job, if nothing else.

Funny fact is that Versed works for about 1 hour. If the patient would have to stay in that pre-test room while tracer percolated in her body, its effect should be mostly over by the time she made it to the table. Benadryl 50 mg PO once or a little dose PO Ativan or even Valium woild be better choice and not requiring any monitorings.

Honestly, Hematocrit, the issue here is the egregious behavior of that RN and the lesson that we all need to be reminded of---patient safety is the reason we do what we do. Vanderbilt isn't going to change, because this facility is a carbon copy of pretty much every other facility like it---where profit is placed above all else.

This^

The bottom line is that I, and I alone, am responsible for my nursing practice. I am not my facility. I am Wuzzie RN. It doesn't matter one bit what environment I work in be it a tertiary Magent facility or a medical tent in the Amazonian jungle. Nor does it matter what obstacles the environment presents. The setting might change but the basic tenets of nursing do not and never will. I choose whether I will hold myself to the high standards that providing safe, competent nursing care requires. It is a decision that everyone here must make. Choose poorly, as this nurse did, and patients will die.

Guys, calm down. I get it. And, I agree.

I think we agree on most things, here.

Guys, calm down. I get it. And, I agree.

I think we agree on most things, here.

I'm quite chill actually. Just sharing ideas.

Specializes in Appeals Nurse Consultant.

Black box warning drugs should all have a 'TIME OUT" and 2 RN's verifying.

Also, Pyxis should not allow for dispensing of these drugs without those two signatures.

Specializes in Surgical Specialty Clinic - Ambulatory Care.

I feel this is a typical story played out over and over again in Healthcare across the nation. All these comments: "How could she not know that versed is not reconstituted? How come she didn't read paralytic agent on the bottle?" Well *******, she didn't know because here in the good 'ol US of A we do the crappiest job of training nurses. 10 years ago, when I was a new grad, my preceptor had been a nurse all of 9 months herself. I worked in a unit of open heart patients that had chest tubes and external pacerwires. No one taught me how to manage these devices because the only person who had worked this floor for more than 5 years was the day shift charge nurse and I worked nights. I mostly learned these devices because of YouTube. Sure as **** didn't learn about how to manage these things in nursing school, which I paid tons of money for. As far as medications go, it wasn't like in school we learned what drugs looked like???? The names of some medications, actions, and concerns I learned some, but it was, by no means an inclusive list! And how many times have you been told to administer a drug that when you look it up doesn't seem to match what you are treating the patient for because the doctor is using it for a secondary or off label use? I am not trying to entirely defend this nurse because this was not an emergency and she should have pushed back and slowed down until she was sure of what she was doing. However, how many of you with bills to pay and kids to support, haven't been pushed into unsafe work conditions because your illustrious employer care more about patient turn over and the bottom line than how safe YOU feel about the speed you are expected to be going at or the overwhelming amount of task/information you are managing?!?!?!?!? Thing is ladies and gentlemen, fear of losing your job does more to encourage nurses to accept the unsafe than it does to foster a "first do no harm" environment. I worked at a facility where I flat out refused an order to discharge a patient because the MD had not preformed medication reconciliation for the patient. It was over the weekend, the doctor yelled at me, I was crying and the CNO of the hospital called me to let me know that I wouldn't have a job Monday because of insubordination, but if I left over the weekend she would write the board for abandonment. I was sickingly upset because all I had done was follow the rules of a safe discharge. Well at the end of my shift that patient coded and that right there saved my job....but I also know that the patient could have easily been fine and I would have lost my job the next day. I don't trust managers, administrators, and anyone running a facility to actually make a decision that is truly in the best interest of a patient if it doesn't help their finances or pisses off the wrong high earning physician. Nurses/CNAs/Nurse Practitioners are scapegoats for facilities and this poor nurse let their unrealistic expectations screw her out of her career and the rest of her life. Most of us HAVE to get a paycheck to survive , so we push it, and then when the chain breaks, we all side with the money and point our self righteous fingers at the one who let it break like s/he was the only reason the system failed. Disgusting. If it weren't for the paycheck and my patients, I'd have given up on this evil career a long time ago.

"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.

And this first rate place has a shortage of nurses. But there was at least one who should have said "no" when she was stretched too far. Already covering for a nurse on break, already stretched too far to even consider doing something as dangerous as conscious sedation.

And what does this say about the surgeon/radiologist and the other staff in the PET room who watched her leave instead of stay and monitor.

Your hallowed hospital, where your dtrs worked - really wow about that, no errors could have been there if your dtrs worked there, wow - is in just as much as every other hospital in the US. And it's all due to $$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$.

Specializes in Critical Care.
"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.

That you have substantiated several mistakes wouldn't reassure the public of quality care. I remember Vanderbuilt as being infamous for the nursing CNO adding housekeeping duties to the nurses for cost cutting measures and how it was well within the nurses duties just ask Florence Nightingale. Does anybody else remember this infamous cost saving scandal from a few years back?

Why didn't they have a procedural nurse or tech to administer this med rather than needing a floor nurse to come down and give it? Such as a radiology nurse as my hospital has for example? Cost cutting measures taken to the extreme! A floor nurse giving versed would need to be off the floor and be monitoring the patient, not just give the versed and leave. This could have been totally avoided if they had a procedural nurse there used to giving versed, rather than fly by night, let's just have the floor nurse drop everything and give versed now. Sounds like a total **** show. How horrible and sad for the poor patient.

This blew my mind. There are many safety actions in place. A warning for sound a likes and where was the pharmacy check? I would never administer any thing without the pharmacy check . Neuromuscular blockades should not be available to a nurse without pharmacy approval. The nurse was clearly wrong giving that med. She/he needs to lose their license. No wonder I am afraid to be admitted to a hospital.