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Nurse Gives Lethal Dose of Vecuronium Instead of Versed

Nurses Article   (234,913 Views 360 Comments 1,069 Words)
by Nurse Beth Nurse Beth, MSN (Advice Column) Writer Innovator Expert

Nurse Beth has 30 years experience as a MSN and works as a Nursing Professional Development Specialist.

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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 29 of Nurse Gives Lethal Dose of Vecuronium Instead of Versed. If you want to start from the beginning Go to First Page.

Nurse Beth has 30 years experience as a MSN and works as a Nursing Professional Development Specialist.

334 Likes; 10 Followers; 81 Articles; 224,792 Visitors; 1,688 Posts

8 minutes ago, mtnNurse. said:

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. 

THIS

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Nurse Beth has 30 years experience as a MSN and works as a Nursing Professional Development Specialist.

334 Likes; 10 Followers; 81 Articles; 224,792 Visitors; 1,688 Posts

On 1/15/2019 at 5:34 PM, Dodongo said:

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...

Right but why was she put in the position of a help all nurse if she was so inexperienced?

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fibroblast has 1 years experience.

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No one will ever see the MBA/CEO or know their name -  staffing for safe ratios and patient safety is not their concern. The responsibility will fall on the nurse. These jobs are like wolves in sheep's clothing.

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8 hours ago, Nurse Beth said:

Right but why was she put in the position of a help all nurse if she was so inexperienced?

Not an excuse. Doesn't matter how experienced you are. If you are giving an unfamiliar med you freaking look it up! She clearly wasn't familiar with Versed.

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I don't see how this one can be explained in her favor. I have had supervisors get upset with me because I told them I wouldn't accept more patients because it was unsafe and I wouldn't be able to provide safe care. One threatened to fire me and I told her to be sure she gave me enough copies to send to my attorney and the board of nursing. They're threatening people with firing and loss of licensure. Those who don't know their rights will submit to the threats. KNOW YOUR RIGHTS!

Having said that, this nurse should have, at minimum, contacted pharmacy to verify or ask about the med. I contact pharmacies all the time to inquire about meds I can't find information on, or I contact the doctor to ask "Why are you doing this *med or procedure*? Please explain it to me because I'm unfamiliar with this and would like to learn more." They're either surprised or glad that I took the initiative to learn more.

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Emergent has 25 years experience and works as a Emergency Room RN.

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My opinion is that she was one of those people who skated through school and her short nursing career by always cutting corners. The hospital probably liked her because she was a time efficient jack of all trades. She may be very personable as well.

It's like the carpenter who gets by for years not using the safety equipment on his saw; one day it will catch up with him and he'll lose some fingers. 

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1 minute ago, Emergent said:

It's like the carpenter who gets by for years not using the safety equipment on his saw; one day it will catch up with him and he'll lose some fingers. 

Yes, but sadly he not only lost his fingers he cut off his co-worker's head in the process.

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Emergent has 25 years experience and works as a Emergency Room RN.

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For what it's worth, I researched this gal online. She and her husband have a 40 acre farm and raise hair sheep. 

Screenshot_20190206-073259_Chrome.jpg

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On ‎12‎/‎1‎/‎2018 at 4:59 PM, TigraRN said:

Mandatory double verification would be helpful for paralytic as well. If we have another RN witness insulin, heparin, amio, why not do the same with vecuronium?

That's an interesting point. I wonder though paralytics are given for intubation which is usually an emergency so I don't know if it's practical. I like the idea though. 

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I sure hope you're just trolling Wuzzie and don't really think you're above this woman's mistake. Yikes!

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20 minutes ago, Crow31 said:

I sure hope you're just trolling Wuzzie and don't really think you're above this woman's mistake. Yikes!

I would never say I don’t make mistakes but I can most definitely say that I have never, ever made a series of such poor decisions and disregarded safety measures as this nurse did and I never will. I don’t give medications that I am unfamiliar with without first looking them up. I monitor my patients appropriately. I ask for help when I need it. I do not allow myself to be rushed to the point of dangerously cutting corners. My one and only med error was giving PO Versed because I failed to check the armband and didn’t realize that the beds had been switched by accident when they were brought back from X-ray within 10 minutes of each other. You can bet I monitored her like crazy and never again assumed I know who a  patient was. It scared the crap out of me. I can and I will say I am above making the kind of mistake the Vandy nurse made because of that med error I made and I am not ashamed to say it. Call me a troll if you wish but you’re wrong. 

Edited by Wuzzie

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HomeBound has 20 years experience.

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47 minutes ago, Crow31 said:

That's an interesting point. I wonder though paralytics are given for intubation which is usually an emergency so I don't know if it's practical. I like the idea though. 

So just an aside.

I received a transfer pt from a neighboring state. Came by ambulance. ACLS protocol, so ACLS crew.

Guy was intubated, so he needed a lot of care. For those RNs who don't take care of intubated pts, or have ever seen one intubated, you (USUALLY, if you're a decent doc) give not just a paralytic, but you also give a sedative as well as a pain relief measure.

This guy was supposed to have a propofol drip going, to keep him sedated for he 4.5 hour long ride.

The ambulance crew didn't have a pump and the sending facility didn't see fit to LEND THEM ONE. So...and here is the absolute scariest solution I could have come up with, besides extubation and bagging...

They gave the ACLS crew (no RN or MD on board) two syringes of propofol and instructed them on how to dose.

When the pt arrived, I was handed a known violent psychiatric patient who had overdosed on handfulls of unknown medications--on nothing.

They had run out of propofol en route. They had either dosed the patient wrong---or this patient was (and I suspect this is the case) just so drug tolerant---and they had to "improvise".

They used rocuronium to "keep the patient sedated".

If I had not been too busy trying to save this guy's life (ICU)---I would have had these two in the RN Mgrs office right then and there. They bolted as soon as they saw my reaction. I usually have to sign for patients, but these guys left. They left a zoll as well. Never came back for it.

This is the state of medicine now in some quarters. TPTB want to pay pennies and require the fewest number of actual, experienced, qualified individuals to do these jobs. If they hired qualified, they'd have to pay for qualified.

I saw a documentary called, "Tell me and I will forget" about the prehospital situation in S. Africa. Watch it. Tell me that administrators and governments and hospitals "do the right thing" by the patients they claim to serve.

My feelings about Ms. Vaught are well documented. However. Hospitals and administrators are enabling this environment.

We hire new grads into critical and sensitive areas where historically, a nurse was required to hone skills in less critical areas, and only move up once PROVEN to be skilled enough to do the job.

Nursing schools are not emphasizing actual nursing care, they are concentrating on "how to further your career" by ....more education. Pharmacology, biochemistry, even medical terminology are being phased out, because "it's too hard" for students to do, and the graduation numbers have to stay high, with the NCLEX pass rates staying high--in order to keep those programs open and student dollars/loans flowing.

Everybody wants to be the boss. Every RN I know wants to be an NP or a CNL or some type of "desk job" so they can get out of direct patient care--they don't give a rat's rump about the projects that they do, the burdensome effect of their ladder climbing "EBP Project" that actually forces floor nurses to do more and more documentation or procedure---thereby less and less actual patient care. All these types care about is getting their Nurse 3 or MSN---and the rest of us have to deal with their cockamamie idea that they sold to management, who all they can hear is..."COST SAVINGS!!!"  And now we've got locked IV setups in a room across the unit that will now take me 15 minutes to retrieve while my patient is crashing and needs access. Because you know....vented patients routinly steal IV catheters out of bedside tables.

Some mental deficient thought that one up at my last place of employment and all it did was add 2000 steps to my day and endanger lives. But that mental deficient got her Nurse 3 out of that assinine project.

The old joke about going to the moon in a rocketship built by the lowest bidder---this is exactly what business does. How can we produce...the cheapest input for the most expensive output?  How can we make the most money and still not kill everyone that comes through the doors?

This won't change, not until every hospital is unionized and nurses have power and a seat at the table. AND I DON'T MEAN NPs and DNPs. I mean...floor nurses, in the trenches, every day schmoes---having a say in what happens in their units.

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