Jump to content

Nurse Gives Lethal Dose of Vecuronium Instead of Versed

Nurses Article   (252,428 Views | 374 Replies | 1,042 Words)
by Nurse Beth Nurse Beth, MSN (Columnist) Educator 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; 234,696 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 24 of Nurse Gives Lethal Dose of Vecuronium Instead of Versed. If you want to start from the beginning Go to First Page.

wondern has 20 years experience as a ASN.

1 Follower; 694 Posts; 11,134 Profile Views

I have read through more than half of the comments in this thread. I have not yet been able to read the 2nd half however I want to go ahead and make one point (forgive me if it has already been brought up).

Everyone keeps mentioning that this is a world class, top notch facility and that overworking RNs has nothing to do with this error.

The hospital admin has in the past demonstrated a flagrant disregard for the nursing profession and what makes us think there are not many many other examples of this? When you have a fairly new "baby" RN orienting another nurse then you can also assume the more experienced RNs have already fled.

I just think it speaks to the overall working environment for the nurses.

"Cleaning the room after the case, including pulling your trash and mopping the floor, are all infection-prevention strategies. And it's all nursing, and it's all surgical tech. You may not believe that, but even Florence Nightingale knew that was true," explained the hospital administrator. The additional requirements include "pull[ing] their own trash and linens, sweep up and spot mop."

Nurses were even told to keep quiet about it.

Nurses Get Bathroom Cleaning Duty At Vanderbilt University Medical Center | Care2 Causes

Thanks, bluebonnetrn. Yes, as soon as I get done cleaning this room and toilet, I'll go hold that baby. Now, that is a brilliant idea! Come on people. It's called the 'germ theory', and on top of it all...as if the nurse isn't overworked already!

Try finding a wheelchair or patient transport in one of these shortstaffed places. I's flat out ridiculous! Nurses can't do everything for everyone. Come on adminisrators, buy some wheelchairs. Hire enough adequate qualified staff.

I bet nurses were told to keep quiet about it!

Share this post


Link to post
Share on other sites

wondern has 20 years experience as a ASN.

1 Follower; 694 Posts; 11,134 Profile Views

A bit off topic, but some have questioned why midazolam (Versed) was ordered and not lorazepam (Ativan), suggesting lorazepam would have been safer. Between the two, midazolam is generally considered the safer procedural anxiolytic. It's shorter acting, so the CNS depressive effects will at least be of shorter duration, and even though both lorazepam and midazolam fall generally under benzodiazepines, midazolam has an added dissociative-like effect which for the same amount of procedure-tolerance effects will produce less respiratory depression and overall CNS depression.

For the dissociative-like effect and decreased respiratory depression...That's why the anesthesia doc used it to help move the boys trapped in the cave underwater through the cave with their individual diver/rescuers. That doctor got their accurate weights to give very accurate doses. Sorry I got a bit off topic too but appreciated your description and just heard the same term, 'dissociative-like effect', in the trapped kids story. It helped the kids not panic going through the tight spaces and caves underwater, some didn't know how to swim even. That's a whole new thread probably on AN somewhere already.

Share this post


Link to post
Share on other sites

24 Posts; 1,130 Profile Views

Audrey2976:

Maybe they are allergic or it would was determined to be too risky of a combination with the current meds? Although benzodiazepines allergies are rare they do exist. Without a pertinent health history, we cannot reasonably surmise why one was chosen over the other. If benzos were off the table for whatever reason, they would need something fast acting which eliminates other anti-anxiety meds generally. I haven't had time to read the full report yet, so please forgive me if it was in there and I haven't gotten to that part!

Share this post


Link to post
Share on other sites

24 Posts; 1,130 Profile Views

Well, I was having a brain-dead moment. I was forgetting that midazolam IS considered a benzodiazepine (I work home health and have limited experience with this drug;therefore, it is outside my wheelhouse). Therefore, please ignore my thoughts about the idea that allergies could have been a contributing factor to the choice of Versed; however, adverse reactions or ineffectiveness may still be a consideration. I know a someone who cannot use any other benzo except lorazepam for their panic attacks because the other meds just do not work as effectively in their body. Also, if the anxiety was more than a simple "talk you down" type of anxiety that was well put and though of (and should be first course of action if the patient does not have history of panic attacks/etc). These are just thoughts.

Once again I am still working on reading the report so I do not know if that is included in it. I will probably state my *actual opinion on this topic once I read the whole thing but I can only look at potentials without having all the information at this point.

Share this post


Link to post
Share on other sites

3 Followers; 5,648 Posts; 27,479 Profile Views

Well, I was having a brain-dead moment. I was forgetting that midazolam IS considered a benzodiazepine (I work home health and have limited experience with this drug;therefore, it is outside my wheelhouse). Therefore, please ignore my thoughts about the idea that allergies could have been a contributing factor to the choice of Versed; however, adverse reactions or ineffectiveness may still be a consideration. I know a someone who cannot use any other benzo except lorazepam for their panic attacks because the other meds just do not work as effectively in their body. Also, if the anxiety was more than a simple "talk you down" type of anxiety that was well put and though of (and should be first course of action if the patient does not have history of panic attacks/etc). These are just thoughts.

Once again I am still working on reading the report so I do not know if that is included in it. I will probably state my *actual opinion on this topic once I read the whole thing but I can only look at potentials without having all the information at this point.

All of that is actually irrelevant to the OP. Nowhere in the literature is vecuronium prescribed for PET scan-induced anxiety. The nurse in question didn't give it because she thought it was a superior option to versed.

Share this post


Link to post
Share on other sites

59 Posts; 1,660 Profile Views

After watching a great special on PBS about the thai cave rescue, my understanding was that the boys were dosed with ketamine.

Share this post


Link to post
Share on other sites

wondern has 20 years experience as a ASN.

1 Follower; 694 Posts; 11,134 Profile Views

I believe it was a combination of the two. It was an interesting show!

Share this post


Link to post
Share on other sites

24 Posts; 1,130 Profile Views

All of that is actually irrelevant to the OP. Nowhere in the literature is vecuronium prescribed for PET scan-induced anxiety. The nurse in question didn't give it because she thought it was a superior option to versed.

I was specifically responding to a question that audrey2976 who asked about potentials of why versed would be prescribed instead of something like lorazepam. I was not directly talking about anything within the report, because as I said I have not finished reading it and want to do so before making any statements about the actual situation. I probably would not have even responded to her had I known that wondern posted such a great response for audrey2976.

Edited by ladysyrah

Share this post


Link to post
Share on other sites

Tenebrae has 8 years experience as a BSN, RN and specializes in Mental Health, Gerontology, Palliative.

1 Article; 1,491 Posts; 11,058 Profile Views

How dare you even say that a nurse should lose her license without knowing her, her work ethic, the quality of her work throughout her tenure, and without knowing all of the facts. The CMS report does not address the nurses experience level, whether or not she had received the training and competence to be a Resource Nurse, and does not address other patient situations that may have led to her being rushed.

...

The nurse overlooked the basic rights of medication administration.

And a patient died, slowly suffocating to death, while being aware of everything that was happening.

The patient didn't just die, her end was appallingly massive amounts of suffering

She needs to under go some very serious remediation before ever being allowed to work as an RN again

Share this post


Link to post
Share on other sites

Tenebrae has 8 years experience as a BSN, RN and specializes in Mental Health, Gerontology, Palliative.

1 Article; 1,491 Posts; 11,058 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.

point is she didnt.

And the patient died, in immense suffering and agony

Share this post


Link to post
Share on other sites

RN-dancer has 2 years experience and specializes in Emergency Department.

45 Posts; 1,196 Profile Views

Idk if other facilities have this but at a previous facility I worked at the nurse would pull said medication and when scanned it had the option to put administered by physician for sedatives and such. But the doc did not actually push the med. Not right

Share this post


Link to post
Share on other sites

Woodenpug is a BSN and specializes in MPCU.

734 Posts; 7,419 Profile Views

Idk if other facilities have this but at a previous facility I worked at the nurse would pull said medication and when scanned it had the option to put administered by physician for sedatives and such. But the doc did not actually push the med. Not right

My epic allows the option "provider administered." It is very useful in emergencies when another nurse actually gives the med. It is also useful when a np/pa or md gives a med. because they do not have pyxis access.

Intentionally misusing this feature would be one case where I would seriously consider a nurse deserving license revocation.

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.