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Nurse Gives Lethal Dose of Vecuronium Instead of Versed

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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. Go to First Page

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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.

Agreed. EPIC has in some facilities, enabled the option to "cut and paste" from column to the next. In other words, I never laid eyes on said 6 patients, yet my charting says that for 12 hours, I regularly rounded, wristbands were on, bed locked and low, call bell in reach, etc.

KPH tells a story in their orientation about an ICU RN of theirs who did just this, but with VS. As RN was checking out her holiday facebook pix and posts...her pt was circling the drain. She had also adjusted the alarm settings to far outside the parameters of someone being an ICU level pt. I don't know the outcome, as KPH kept the whole thing hush hush. RN was terminated, but got her job back because of a grievance procedure thru the union. They argued that if EPIC hadn't enabled the feature, and KPH hadn't allowed the feature, she wouldn't have used it.

The RN was reinstated, and relegated to a "less challenging" job description. No charges were brought to the state level, bc....oh.....well.....hmmm.....the same reason Vanderbilt didn't self report and report this RN to the TBON?

There is no standardization with the technology--but even so---this all comes down to the integrity of the RN and of the facility that employs the RN. Vanderbilt's orientation, training, screening, policies and procedures needs a serious look---by an outside and unbiased observer.

The RN needs to....be investigated by the TBON and be grateful if they don't revoke her license and/or she gets a civil suit slapped on her by the family of this patient.

This really goes to the professionalism, integrity, training and work culture of Vanderbilt. This RN seemed to believe that this behavior was acceptable, and maybe it is at Vanderbilt---which is why a thorough investigation by an unbiased third party needs to happen.

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My main question is was Versed even necessary in the first place. IV Benadryl, Ativan or valium would've done the job right? Im not a bedside nurse anymore but seriously does a 75 yr old woman require Versed to get any scan?

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My main question is was Versed even necessary in the first place. IV Benadryl, Ativan or valium would've done the job right? Im not a bedside nurse anymore but seriously does a 75 yr old woman require Versed to get any scan?

Although the issue was not the particular drug that was ordered (versed), it was the RN's appalling lack of standard safety practices...

Even had she given IV benadryl, Ativan or Valium--you never, ever leave a patient without assessing their response, when giving these types of IV medications. The patient was elderly, with change of mentation and a brain bleed. You don't give iv sedatives, antihistamines (which have a sedating effect), or anti-anxiolytics and just walk away. Period.

It doesn't matter what was ordered. It mattered that this RN didn't pull the correct drug in the first place, overriding all safety protocols in place to prevent her from doing exactly what she did. On top of it, she clearly didn't know anything about this patient...and believing she had a syringe with Versed in it....she.walked.away.without.assessing.this.patient. Elderly patients can have very different responses to IV sedation, which is what the RN believed she was administering.

She failed on every count. I agree that this pt should never have even been ordered IV sedation for a PET scan in the first place...

which again leads right back to the appalling lack of judgement in this RN. She should have advocated for this patient. Maybe no medication was necessary. Just as another poster suggested....slow the hell down and sit for a minute with this poor woman. Maybe all she needed was an explanation of what was happening.

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So, a nurse:

diverts a narcotic, but only once...

logs into the chart of a patient on another floor, but only does it one time...

comes to work drunk, but only once...

Or kills a patient, but only once...

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The contradiction of the statement ... Vande is run by expert knowledgable people, to I have personally investigated SEVERAL SENTINAL EVENTS is amazing to me. I need a very big googly eyed emoji for this Davey!

Cheers

You have no idea what you are talking about. No one is perfect and this is a VERY large medical center. Mistakes and tragic ones happen when so many humans are involved. Not defending what happened...at all. You must not be aware of the sentinel events which undoubtedly occur where you are employed.

If you are going to quote me please use the quote feature. It is Vandy and sentinel.

Edited by twinsmom788

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quote 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

mix it STERILE WATER (she had to freaking draw this in a syringe!) This took time, effort. Another good place to stop. end quote

Very true...human error and obvious system failure were to blame here.

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Yeah, but in addition to all the nurse did wrong, the hospital covered up the error by mischaracterizing the death to escape the post-mortem evaluations of what went wrong.

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Whether the study should have been done inpatient or outpatient is a moot point. That is not a nursing call. Whether the pyxis machine should have been able to be overridden is also a moot point. Basic nursing 101 and the 5 rights of medication administration is what applies. It is a grevious error resulting in the death of a patient. I can see no fault with the physician, or the pharmacist. Maybe the nurse was overwhelmed and tasked to an unsafe level, but she still chose to accept that assignment and failed to provide due care and meet the standard of nursing care by not following the 5 rights rule.

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We order PET's daily. NEVER do we order Versed for "claustrophobia". MAYBE Ativan. Talk about over-medicating!!

I also needed to comment on the "red cap" part of the article. Our B12 comes with a red vial cap, clearly red is not the universal warning sign of a dangerous medication

Edited by Decitabinequeen
added a thought

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We order PET's daily. NEVER do we order Versed for "claustrophobia". MAYBE Ativan. Talk about over-medicating!!

I also needed to comment on the "red cap" part of the article. Our B12 comes with a red vial cap, clearly red is not the universal warning sign of a dangerous medication

It's already been discussed why this was ordered. Versed has a shorter half-life which is desirable with neuro patients.

Point taken on the red cap thing but still you would have thought the "paralytic agent" printed in big white letters on said red cap would have made a thinking person pause for a moment.

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if anyone is shocked that such an error could happen, read this compilation of errors involving paralyzing agents:

Paralyzed by Mistakes - Reassess the Safety of Neuromuscular Blockers in Your Facility | Institute For Safe Medication Practices

I don't think any one of the errors in the article rise to the level of negligence involved in this case however, although some of them are pretty mind-boggling.

Edited by mtmkjr

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The kind of anxiety produced by the claustrophobia of a scanner tube is not something that can be shushed away by some hand-holding and kind words. I went for a cardiac MRI this summer and discovered that I have some lingering PTSD from my experience with congestive heart failure last year, during which I had to lie flat for studies while drowning in my own lungs. I had no idea I would react as I did! I even had an MRI of my injured hip when I came home from deployment in 2014, so I was really surprised by my utter panic. I had to halt the scan - super embarrassing, but there was no way I could talk myself through enduring an hour of what is an interactive scan in that MRI tube (open MRIs are not suitable for cardiac MRIs, unfortunately). I had to get a dose of PO Valium prescribed by my electrophysiologist and reschedule the scan. I knew it wasn't rational, but I could not have done it without 10mg of Valium. So yeah, I totally understand why this patient needed something (definitely not vec!!!) for her study. Poor woman.

I was thinking the same here. Talking doesn't help claustrophobia....but is a bit beside the point. Whatever the med prescribed and for whatever reason, the errors here were profound.

This whole story obviously brings up so many issues. Nurse practice acts, punitive culture, contributing factors, accountability, responsibility, basic nursing knowledge, etc....And I can hardly wrap my head around how someone in this "Resource" roll did not know that she was administering a paralytic????? NONE OF THIS MAKES SENSE.

I've made my share of mistakes after 30 something years in practice and have learned from each and every one of them. I've done work arounds and now NO LONGER DO. I've pulled and given wrong meds in haste doing overrides and NO LONGER DO. I've seen others' mistakes and changed my own habits as a result.

As I have sympathy for this nurse and am to the point of anger towards the pressures we face by administrators who care only for their bottom lines....I still can't get my mind around how a Reaource nurse in an ICU setting could have made THIS mistake?????

SHE IS ACCOUNTABLE to be sure. However, I still believe this hospital WRONGLY had her in this role. Vanderbilt has BIG accountability in this one point alone. She obviously did not have the knowledge, training, and/or skills to be in this role, let alone the appropriate integrity, and personal accountability, in that she agreed to work in this role in the first place.

(I stumbled on wording, but I think my points are clear)

Edited by BeenThere2012
Wording

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