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 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.
Here is a timeline of events, where the time was documented.
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.
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
It was most likely the PET technologist that called the rapid response at the end of the scan when they attempted to move the patient from the scanner.
I don't believe she actually made it to the scanner. She was dosed for the scan, medicated by the float nurse and then placed in the pre-scan holding area where she remained for approximately an hour from what I remember when I read the report. There was a camera on her but it wasn't sensitive enough to monitor respiration.
I'm not sure what Nurse Beth is hoping for here, or if there's anything further for me to add to some of the excellent comments already made, but there is one cardinal rule which all nurses should follow. If you don't know what it is, or what it's used for, don't give it. If you can't find out what it's used for and there's no one there to tell you, don't give it. And if you have given any elderly patient a medication which may have unknown effects, put them on a monitor. Even a simple SATS monitor would have been screaming the place down, the moment her breathing stopped. I have to question the level of pharmacological knowledge of any nurse who does not recognise a word that ends in Curium or Curonium as being of the family of neuro muscular blockers. Only succinylcholine does not conform to that formula, although its other name, suxamethonium, has some similarity. A horrible death, wholly preventable, and I grieve for her family and pity the nurse.
I'm trying to add something meaningful.
I will say this about Vandy. My experiences with Vandy are several years old - however, their clinical processes and systems approaches to care were squared away. One must keep in mind that humans can defeat a process or system.
IMHO it was human error/systems error. I'm going with a 90/10 ratio on the nurse. And it's a tough call.
Only because even if she DID NOT KNOW what the DRUG was for presuming she's not dumb butt stupid
- PARALYZING AGENT - could she not read English language words with meanings -- it
should TRIGGER another RUH-ROH when she had to mix it STERILE WATER (she had to freaking draw this in a syringe!) This took time, effort. Another good place to stop.
Vecuronium/Norcuron is rarely to NEVER mixed with NS -- always sterile water or D5 or it burns like mad.
She carries this from NeuroICU.
I genuinely mystified.
This nurse is ORIENTING another (presumed experienced) RN to a "help all" spot -- What the Heck?
Give a Med and Hit the Road? So 2 nurses are actually doing this in some manner?
Nope.
Anyway. We all know what went wrong.
I do wonder if Versed had been in shortage in some way contributed to stock, par issues? On a NeuroICU I'd expect to see that heavily used.
Systems staffing adds to the issue.
I've been in 18 facilities as either staff, contract, travel or PRN and as ground/flight I've transported out of 50+ more in every area of whatever facility (I take them from wherever they call). I assure everyone any ICU patient going anywhere intrafacility for any reason goes with an ACLS RN and a Monitor/Defib and initial resus box. Period. I've untangled plenty of desperate situations.
Can you imagine the horror?
As an integrity test, this is a failure.
"Clean Kills" are very bad things.
God help us.
:angel:
I'm a registered RT®, CNMT, PET technologist, and RN. The PET scans usually run for 3 minutes to cover a small area and then moves down. The reconstruction the images must go through takes at least another 3-5 minutes on most cameras. A quiet environment is critical in order to minimize patient motion (startle). F-18 FDG is a glucose analog that gets trapped inside cells over an hour long period. Panic occurring during scanning would not change the FDG uptake pattern on the images. An "eye to thigh" scan would take 8 "beds" at 3 minutes each = 24 minutes. It was most likely the PET technologist that called the rapid response at the end of the scan when they attempted to move the patient from the scanner.
Except that patient apparently spent all those 30 min in "hold room" monitored by tech sitting somewhere else and camera waiting for tracer distribution. She was not under scanner at that time.
And, depending on what and how they are scanning the brain for, effects of strong emotions such as panic can be seen. This is one reason why fPET is such a fascinating thing for mental disease studies.
I don't believe she actually made it to the scanner. She was dosed for the scan, medicated by the float nurse and then placed in the pre-scan holding area where she remained for approximately an hour from what I remember when I read the report. There was a camera on her but it wasn't sensitive enough to monitor respiration.
vec was removed from Pyxis at 1459, code was called at 1529. During this 30 minute period is when the vec was administered.
S Hall, ADN, BSN, RN
11 Posts
It said that she never documented it anywhere.