Jump to content

Nurse Gives Lethal Dose of Vecuronium Instead of Versed

Nurses Article   (252,353 Views | 374 Replies | 1,042 Words)
by Nurse Beth Nurse Beth, MSN (Columnist) Writer Innovator Expert Nurse

Nurse Beth has 30 years experience as a MSN and specializes in Med Surg, Tele, ICU, Ortho.

18 Followers; 103 Articles; 234,632 Profile Views; 2,059 Posts

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

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

KathyDay specializes in Patient Safety Advocate; HAI Prevention.

1 Article; 26 Posts; 2,568 Profile Views

I am a retired RN, who graduated nursing school in 1970. Most working nurses now would consider me a dinosaur, and in most cases they would be absolutely correct. But, some things have not changed. The 5 rights of medications is still the rule of the land, correct?

Another thing that has not changed is that nurses are considered expensive bodies in the workplace, and nothing more. Hospitals expect all nurses to know all nursing things and that is just horribly unsafe. Nurses generally specialize and learn specifics of that specialty early on. Some then become certified. I was an ER nurse so sending me to Maternity would haven been very dangerous for Moms and babies.

Nursing graduates come out of nursing training or college programs and start jobs in busy hospital settings. When I did that, I learned quickly that I had to learn short cuts, and work arounds to survive a shift. I don't think that has changed either, and it must. Until Hospitals observe mandatory nurse to patient ratios, that will never happen and things like this tragic horrid harm will continue happening. Non specialized nurses will be expected to do specialized tasks, without the appropriate experience or certification, because hospital management mentality is that a nurse is a nurse is a nurse. That is simple not so.

Also, the list of things that went wrong in this article....#1 should have been "The patient died and it was 100% preventable".

I work as a patient safety advocate/activist these days, and the stories I hear about preventable harm and death are astounding. It simply cannot stand. We as the bedside nurses of the world must put a stop to it.

Share this post


Link to post
Share on other sites

7 Followers; 3,412 Posts; 24,088 Profile Views

We as the bedside nurses of the world must put a stop to it.

Agreed and it starts with us, with each nurse examining their own practice. We need to take an honest look at bad habits we may have developed, at shortcuts that could lead to patient harm, at what we are teaching our young nurses. Do we model exemplary nursing practice or do we let things slide because somewhere along the way this nurse determined that she did not need to follow the rights of medication administration. How many more shortcuts will it take for me to be in her shoes? Although unlikely to happen because I am inherently a rule follower this story is a cautionary tale for all of us.

Share this post


Link to post
Share on other sites

380 Posts; 3,440 Profile Views

I'll tell you a story of my own. I was called in to go to work- there was a call out. When I arrived, I was told there was a code and I would be taking care of the post-code patient. The nursing supervisor called and asked me to come to the floor to care for the patient during transport, imaging, etc etc. I had no other patients and even though my charge nurse didn't want me to go to a unit I wasn't trained on, I still went.

Essentially, I used the nurses and aides as my gofers while I cared for the now intubated patient in a non-ICU. We were ready for transport- portable vent, monitoring, code meds, ambu bag, everything was ready. But, a CXR to confirm placement was still pending. The doctors, and the nurse supervisor, were pressuring me to go straight to the ICU and we can confirm placement there. Although I was newer to this hospital, I remember from my previous hospital to never transport post intubation until we have a CXR conforming placement. Well, it was my patient so I told the sup and the MD that I'm not going anywhere until we get the CXR and if they want to move the patient, then I need to endorse the patient to another nurse.

We waited for the CXR.

I guess the point of my relatively uneventful story is that many times, supervisors and docs will pressure us to do things that are not safe- that go against best practice and we always 100% of the time have to stand our ground and respectfully tell them to F off or bring another nurse.

To say a nurse should lose her license without even conducting an investigation is unprofessional and quite frankly, goes against the Nurse Practice Act of every state and territory of the USA.

Your story raises red flags with me, and I don't think it confirms the point you were trying to make, but its partially it's because we don't know your background and experience. Were you icu/ Er trauma trained at this point? Had you cared for vents/ post arrests before. If not, that was a very unsafe assignment to accept as you would have had a huge knowledge deficit.

I disagree that you shouldn't move a patient before the ett is confirmed, but every hospital I've worked at has a portable X-ray team. Had the X-ray been done already? Why couldn't the Er doc have confirmed the X-ray then and there. I would argue that delaying the patients arrival to icu is far less safe than waiting for cxr placement. At least in icu, you are surrounded by resources and supports for your patients: nurses who are familiar with the drugs needed, intensivists etc. My experience is that even if the intensivists have written orders down in ER, unless it prevents the patient from crashing, ER just doesn't have time to implement the interventions, including targeted temperature management, I would be concerned about delaying interventions such as these.

I agree that doctors will sometimes ask us to do things that are outside our scope of practice, or against policy. But often explaining what the policies are is enough. With this story, I don't think the resource nurse was outside her scope of practice to escort the patient. It as when she received an order for a medication she clearly wasn't familiar with and gave the wrong one and wasn't aware of the required monitoring afterwards that the nurse decided to practice beyond her scope and this event unfortunately happened. She made several errors including not doing the basic rights of medication.

Edited by Triddin

Share this post


Link to post
Share on other sites

ZenLover has 6 years experience as a BSN and specializes in ICU.

118 Posts; 3,455 Profile Views

My guess would be this nurse had little experience. I have seen too many times administration wanting to grab up someone who is young, willing to please them and listen to them say "you can do it all". To be a resource nurse and precepting without the experience to understand the difference between these two drugs or the importance of monitoring says it all. This would not be me because a year or two after being a new nurse I put aside making "suits" that I worked for happy and focused on safety. I started saying no. I may not be an "office" favorite....but perhaps one day someone will appreciate that I will hopefully not be a reason for a CMS visit. But by the Grace of God go any of us. Too many new nurses, not enough support and not enough back bone to learn to say no....because sometimes you have to in order to advocate for your patient and yourself. How sad for everyone. I wish this nurse the best. I can't imagine.

Share this post


Link to post
Share on other sites

pseudonym87 has 1 years experience.

24 Posts; 196 Profile Views

Of course I was ICU trained. I was going to take the post-code patient on the unit but the sup called up to start caring for the patient on the floor until patient was able to be given a room (pretty sure I mentioned this in my initial post).

I recalled the policy from my previous hospital that you should not transport a patient after a fresh intubation until placement is confirmed with CXR. After this situation, I investigated, and the same policy was in place at this facility as well.

The portable x-ray team had not arrived yet, co2 capnography was not used during intubation and I sure as heck wasn't moving that patient unless I was certain that I had a secure airway. Sorry, breath sounds don't cut it and I would say airway trumps cooling measures (I continued caring for this patient finally in the ICU until the end of my shift and cooling was not indicated. Just a few vasoactives, fluids, a-line, central line. There were no delays in care. Your red flags seem to ignore the potential for an unconfirmed airway to lead to respiratory arrest en route.

My point is that you have to stand your ground. Maybe this nurse was summoned to the ER urgently and made the stupid decision to save time rather than to be safe. Instead, she should have properly administered the versed and stayed with the patient. She should have stood her ground and not be rushed to the next task.

I'd like to know if a supervisor was aware that she was going to administer versed and then rush to the ER. There's something missing in this story.

Edited by pseudonym87

Share this post


Link to post
Share on other sites

HomeBound has 20 years experience and specializes in ED, ICU, Prehospital.

1 Follower; 242 Posts; 1,372 Profile Views

It's unprofessionalism which also violates the nurse practice act. You have not seen everything the board of nursing will weigh in their determination to take action against her. To think that you can adjudicate on someone's professional licensure based solely on a review of content released to the public without taking account other evidence is unprofessional and this violates the Nurse Practice Act in all states.

Of course I take issue with the errors made by the nurse, the physician, the charge nurse, the pharmacy, etc. She ignored basic checks but we need to determine if this is a pattern of behavior or an isolated incident before we revoke her license in the court of public opinion.

Pseudonym,

I think Wuzzie and others have fully informed you that having an opinion isn't "aginst the Nurse Practice Act", simply because it disagrees with your personal belief.

That said. You show a very serious lack of understanding of the situation, as well as your own practice. Because of your, "It isn't the offense that is the problem!!! It's YOUR REACTION TO IT!!!"

I cannot take your criticism of my opinion seriously. You didn't address the original problem with any type of factual information.

You didn't state any portion of any Nurse Practice Act that I may have violated, in any way.

You simply had a knee jerk reaction because it insulted your vast years of experience in Nursing. I can make assumptions here, such as...you have made these mistakes yourself and have never been made accountable or you see absolutely nothing wrong with violating rules when it suits you. I don't know you. I don't know what kind of Nurse you are--maybe you are the Nurse in question. Maybe you are a friend or relative of the Nurse in question. Maybe you work for Vanderbilt.

Lots of maybes.

But the basic FACTS are that this Nurse violated hard, fast, RULES that a nurse in her first year should know never to break. Not ever. Whether it's a habit not to break them and you just don't know WHY those rules exist or not.

It is not unprofessional to assess a Nurse's performance and deem her, BECAUSE OF FACTUAL, DOCUMENTED PROOF, that she is not adhering to the basic tenets of nursing practice....and advise that perhaps...she needs to find another line of work.

How would anybody ever have an accurate nursing review or any policies/procedures be changed if nobody was ever held accountable for their performance? How would we ensure safe patient care if everybody just pats the bad actor on the shoulder and says..."better luck next time"?

Just because someone passes the NCLEX doesn't mean a damn thing. She's not entitled to anything. Nor are you. Nor am I. Remaining a practicing nurse means a ridiculous amount of responsibility, vigilance and skill. Whether you like it or not, that is the reality of it. If this isn't something someone feels is "fair" to have place on their shoulders, then nursing is not for them.

I sound harsh, and that is just fine with me. My mother was taken care of by a nurse with that same lax attitude. Post AAA and had the call light on for an HOUR to get an ********g bedpan brought to her. IN AN ICU. That RN was far too busy chatting it up and being just the cutsie pie and was just so, so tired of that whole "one on one critical care thing" because it is DEMANDING. My mom ended up on the floor trying to walk herself to the bedside commode.

I made it my mission to report that RN to the BON. Vindictive? Hmmm. So you would want your mother or father treated like that because Miss 1 Year ICU right out of nursing school "was going to get to it" even though she was 1:1?

Have done and will do it again. I self report. I see younger nurses just flinch and withdraw when they see someone self report...they would never do that! Too much like taking responsibility for their actions! Because....gasp......consequences!

It's sad when a nurse goes down for their actions, because there ARE other factors in play. I don't deny it and I am an advocate for UNIONS and RATIOS across the board, if you have seen any of my posts.

But Southern nursing is a whole other beast in and of itself. Their attitudes are very, very different (ADMINISTRATIVELY) than pretty much anyplace else I have ever worked. It's clear from day 1 that you serve at their pleasure and if you don't do it their way, it is the highway. If that means you will take 12 highly acute patients in an Level 1 ED because they haven't staffed CNAs or filled the 3 call outs....then that is what you will do. If you complain, you will find yourself on the fast track to sitting psych right before you are given the choice to quit or be fired. You never, ever bad mouth any of those huge systems....and expect to come out unscathed, whether you were right or wrong.

So. My advice to you is to read the NPA, come back and quote the portion that I violated and we can start another thread where others can weigh in without distracting from the FACTS OF THIS CASE and this RNs negligent performance.

Share this post


Link to post
Share on other sites
Guest
by Guest

0 Posts; 0 Profile Views

Instead, she should have properly administered the versed and stayed with the patient.

But she didn't even administer Versed/midazolam, let alone do it safely. She overrode safety protocol and withdrew the incorrect medication, administered it in a entirely unsafe manner, which resulted in what was likely a horrific death.

Share this post


Link to post
Share on other sites

pseudonym87 has 1 years experience.

24 Posts; 196 Profile Views

Right- but let's say she did the right thing and stayed with the patient, she would have most likely saved the patients life.

Share this post


Link to post
Share on other sites

1 Follower; 307 Posts; 2,114 Profile Views

It's unprofessionalism which also violates the nurse practice act. You have not seen everything the board of nursing will weigh in their determination to take action against her. To think that you can adjudicate on someone's professional licensure based solely on a review of content released to the public without taking account other evidence is unprofessional and this violates the Nurse Practice Act in all states.

I think you are mistaking commenters chatting here on a public forum with the BON.

Share this post


Link to post
Share on other sites
Guest
by Guest

0 Posts; 0 Profile Views

Right- but let's say she did the right thing and stayed with the patient, she would have most likely saved the patients life.

Lets say she did the right thing and: 1. pulled the correct med, or 2. didn't use an override, or 3. checked the medication before administering, or 4. checked the dose before administering it, or 5. re-evaluated the patient after administration. Any one of these might had saved a fatal error (all of them, not just one, is standard of care), which is exactly why this is gross negligence that resulted in a fatality.

Edited by BostonFNP

Share this post


Link to post
Share on other sites

pseudonym87 has 1 years experience.

24 Posts; 196 Profile Views

Pseudonym,

I think Wuzzie and others have fully informed you that having an opinion isn't "aginst the Nurse Practice Act", simply because it disagrees with your personal belief.

That said. You show a very serious lack of understanding of the situation, as well as your own practice. Because of your, "It isn't the offense that is the problem!!! It's YOUR REACTION TO IT!!!"

I cannot take your criticism of my opinion seriously. You didn't address the original problem with any type of factual information.

You didn't state any portion of any Nurse Practice Act that I may have violated, in any way.

You simply had a knee jerk reaction because it insulted your vast years of experience in Nursing. I can make assumptions here, such as...you have made these mistakes yourself and have never been made accountable or you see absolutely nothing wrong with violating rules when it suits you. I don't know you. I don't know what kind of Nurse you are--maybe you are the Nurse in question. Maybe you are a friend or relative of the Nurse in question. Maybe you work for Vanderbilt.

Lots of maybes.

But the basic FACTS are that this Nurse violated hard, fast, RULES that a nurse in her first year should know never to break. Not ever. Whether it's a habit not to break them and you just don't know WHY those rules exist or not.

It is not unprofessional to assess a Nurse's performance and deem her, BECAUSE OF FACTUAL, DOCUMENTED PROOF, that she is not adhering to the basic tenets of nursing practice....and advise that perhaps...she needs to find another line of work.

How would anybody ever have an accurate nursing review or any policies/procedures be changed if nobody was ever held accountable for their performance? How would we ensure safe patient care if everybody just pats the bad actor on the shoulder and says..."better luck next time"?

Just because someone passes the NCLEX doesn't mean a damn thing. She's not entitled to anything. Nor are you. Nor am I. Remaining a practicing nurse means a ridiculous amount of responsibility, vigilance and skill. Whether you like it or not, that is the reality of it. If this isn't something someone feels is "fair" to have place on their shoulders, then nursing is not for them.

I sound harsh, and that is just fine with me. My mother was taken care of by a nurse with that same lax attitude. Post AAA and had the call light on for an HOUR to get an ********g bedpan brought to her. IN AN ICU. That RN was far too busy chatting it up and being just the cutsie pie and was just so, so tired of that whole "one on one critical care thing" because it is DEMANDING. My mom ended up on the floor trying to walk herself to the bedside commode.

I made it my mission to report that RN to the BON. Vindictive? Hmmm. So you would want your mother or father treated like that because Miss 1 Year ICU right out of nursing school "was going to get to it" even though she was 1:1?

Have done and will do it again. I self report. I see younger nurses just flinch and withdraw when they see someone self report...they would never do that! Too much like taking responsibility for their actions! Because....gasp......consequences!

It's sad when a nurse goes down for their actions, because there ARE other factors in play. I don't deny it and I am an advocate for UNIONS and RATIOS across the board, if you have seen any of my posts.

But Southern nursing is a whole other beast in and of itself. Their attitudes are very, very different (ADMINISTRATIVELY) than pretty much anyplace else I have ever worked. It's clear from day 1 that you serve at their pleasure and if you don't do it their way, it is the highway. If that means you will take 12 highly acute patients in an Level 1 ED because they haven't staffed CNAs or filled the 3 call outs....then that is what you will do. If you complain, you will find yourself on the fast track to sitting psych right before you are given the choice to quit or be fired. You never, ever bad mouth any of those huge systems....and expect to come out unscathed, whether you were right or wrong.

So. My advice to you is to read the NPA, come back and quote the portion that I violated and we can start another thread where others can weigh in without distracting from the FACTS OF THIS CASE and this RNs negligent performance.

Texas law further explains violations of the NPA as Providing information which was false, deceptive, or misleading in connection with the practice of nursing; By adjudicating action against a nurse without having all of the information a Board of Nursinf would request, you are being deceptive and are therefore in violation of the NPA. Other states has vague statutes that provide broad powers to regulate every aspect of a nurses life. With that said, it's still a violation.

Now, just to clarify, I have no connection to any of the involved parties at vanderbilt. The solution of firing someone and revoking a license should occur after it has been proven that a pattern of behaviors have led the board to believe, that it is in the best interest of the public for someone to no longer be allowed to practice. This one incident, although a horrible outcome, is not a pattern. Why can the hospital provide a corrective plan and be allowed to stay in business but the nurse can't be placed on a PIP? The reason why I am even concerned with the nurse is because I care about our profession. Yes we must keep the public safe. We also must hold ourselves accountable but in a way that doesn't create a blame culture and promotes a just culture. We're professionals.

And just to address your rude assumptions- I'm lucky to have never been put in a situation where one of my patients were harmed because of my actions. We're all human. I, however, as a supporter of nurses, supporter of unions, and former union delegate would fight for this nurse because I promise you she didn't walk into work saying, "I want to hurt someone today." She's not a criminal- she made a series of stupid mistakes and she should be held accountable and placed on a PIP.

Share this post


Link to post
Share on other sites

pseudonym87 has 1 years experience.

24 Posts; 196 Profile Views

I agree. Absolutely gross negligence. The entire person needs to be assessed- her work performance evaluations, previous incidents, etc. Using The Whole Person method, she can be appropriately disciplined and absent any evidence pointing to a PATTERN of gross negligence or misconduct, remediate and reintegrate the nurse.

Share this post


Link to post
Share on other sites
×

This site uses cookies. By using this site, you consent to the placement of these cookies. Read our Privacy, Cookies, and Terms of Service Policies to learn more.