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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. You are reading page 28 of Nurse Gives Lethal Dose of Vecuronium Instead of Versed. If you want to start from the beginning Go to First Page.

This is probably why the nursing profession is pushing for everyone to be very specialized and a year or two into almost all specialty means getting pigeonholed. When I went into nursing people talk about its flexibility and most of my instructors have several years experience in different specialties each. Now we are just expected to work in the same setting for the rest of our careers. Few nurses like the one in this articles is the reason why people who want to change specialties aren't given a chance at all. Been working in psych for most of my time as a nurse but even I know the difference between Versed and Vecuronium. 

Edited by Seeing Myself Out

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So wait, I'm new to this party...  but you are telling me that the nurse pulled a med (that s/he was OBVIOUSLY not familiar with) from the accudose, and went through all the trouble of *reconstituting* it (which means she had to read the package insert or something to make sure she reconstituted it appropriately!!) and never stopped for one second to think s/he should look it up?  I mean, it's hard to explain this one away...

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Typed in VE and automatically go with the first drug that comes up on the list? IF this is true it's extremely reckless and dumb.

 

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On 1/18/2019 at 5:15 AM, nycmoon said:

Typed in VE and automatically go with the first drug that comes up on the list? IF this is true it's extremely reckless and dumb.

 

It's true. The only real "good thing" to come out of this are changes in how various hospitals handle these high-risk drugs because of the conversations across the healthcare spectrum surrounding this occurrence. I have an EMS and ED/trauma background so I am blessed with familiarity of a wide range of meds, and it wouldn't even occur to me that paralytics don't need to be in every Pyxis. But I know our hospital took a look at where these types of meds should really be, and removed some from certain areas. 

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The Vanderbilt nurse was arrested today for reckless homicide and patient abuse.  

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41 minutes ago, MierKat said:

The Vanderbilt nurse was arrested today for reckless homicide and patient abuse.  

Do you have a link? 

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42 minutes ago, MierKat said:

The Vanderbilt nurse was arrested today for reckless homicide and patient abuse.  

Just read the article about it here: https://www.tennessean.com/story/news/health/2019/02/04/vanderbilt-nurse-reckless-homicide-charge-vecuronium-versed-drug-error/2772648002/

I had to look up the definition of reckless homicide in Tennessee, which is explained here: 

"Reckless homicide and criminally negligent homicide are more loosely defined in Tennessee to address the wide variety of behaviors that could be considered beyond the realm of acceptable to the degree that the actions are criminal. One example of reckless homicide is playing Russian roulette by picking up a gun with a single bullet in it and shooting it at a friend. There's a substantial risk the friend will die. In comparison, picking up a gun you believe is empty but failed to check before shooting at your friend could be criminally negligent, as you should have looked to be sure it was empty but had no knowledge or belief that it was loaded."

To me, what she did seems more like their description of criminally negligent homicide.  At any rate, the whole thing is incredibly sad and puzzling.

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Can't even put a thought together right now.

The whole thing makes me feel physically ill.

Quote

Vanderbilt quickly provided CMS with a corrective plan so the reimbursements were no longer in jeopardy.

Well thank zeus for that.

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I'm not sure how to search here...

Has the dose given been known before?  She apparently gave 10mg. That's a pretty hefty dose, is it not?  I do not work in an area that uses Vercuronium, so I do not know for sure... but I looked it up and induction is .08-.1mg/kg. So that would have been max dose for 220 lb person. 

So the dose of Versed was 2mg and she gave 10mg Vercuronium... not one bit of sense to make out of it.


 

Quote

 

 A second nurse found a baggie that was left over from the medication given to the patient.

“Is this the med you gave (the patient?)” the second nurse asked the first nurse, showing her the baggie, according to the report. “This isn't Versed. It's vecuronium."

 

😱😱😱

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On 12/1/2018 at 9:08 PM, Nurse Beth said:

What if there was not a culture of expediency, to get the job done at all costs, and hurry up?

[and in another post:]

On the one hand, nurses are told to refuse unsafe assignments..... but in reality the pressure is to comply.
[...]
If they refuse, they are at risk for everything from not being considered a team player to being scorned to being fired.

On 12/2/2018 at 3:00 AM, 3ringnursing said:

I've been in plenty of unsafe work situations where the pressure to "just do it" was a very real expectation, along with insanely unrealistic workloads. In that setting things can quickly spin out of control where suddenly you realize to your horror things have now gone sideways. Every nursing job I've ever resigned from was because of very real danger to patients and myself. It is much more common than than I'd ever thought possible.

THANK YOU both for pointing out what I think it most always boils down to -- patients aren't safe because of unrealistic work loads and not enough staff. No amount of new initiatives to fix safety issues will change the fact that when you don't have enough staff or when unrealistic work loads are placed on staff, patients will be harmed. No amount of warning labels on vials, multiple new steps of verification on Pyxis, signs stuck on doors and above beds, second nurse witnessing, cameras in med rooms, or flying mini-drones with video cameras around the heads of RNs all day is going to prevent a patient death so long as there's money to be made from short-staffing. 

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