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?
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