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Nurse Gives Lethal Dose of Vecuronium Instead of Versed

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by Nurse Beth Nurse Beth, MSN (Columnist)

Specializes in Med Surg, Tele, ICU, Ortho. Has 30 years experience.

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

blondy2061h, MSN, RN

Specializes in Oncology. Has 15 years experience.

I don't at all get your premise that this was an unnecessary test done in the wrong setting. Or that had it been done outpatient no sedation would have been ordered.

I don't understand that either. If she was sick enough to require an ICU or a SDU clearly she wasn't appropriate to have an outpatient test. Sometimes a PET scan is required to guide treatment plans. Working in oncology I have seen many an inpatient get a PET scan.

And yes, outpatients get sedation but it's usually PO. Vecoronium doesn't come PO, but if the nurse got this far in this error, who is to say they wouldn't confuse the route also?

What if Vanderbilt had protocols in place around administering conscious sedation? Such as training to include patient monitoring.

You have mentioned conscious sedation (aka moderate sedation) a couple of times; just want to mention this was not the intent of that order. It was an anxiolytic dose of midazolam (minimal sedation/anxiolysis). I understand your point though - anyone who works with any of these meds should have the appropriate procedural sedation training.

If the order was reviewed by pharmacy, why was it not profiled? This would have eliminated the need for an override.

The order (for Versed) had been verified by pharmacy, so presumably it was profiled. The nurse reported to CMS investigators that she searched for Versed under the patient's profile. If you are working (searching) within a list of generic names, Versed obviously is not there. The nurse then went into override mode and searched "ve."

This is definitely a good idea, but unfortunately it would not have saved this pt as she did not scan the med. Just scanning it would have given her a hard stop since the Vec wasn't ordered. That also makes me wonder, would she have not scanned the Versed?

This is an assumption, but since med scanning technology was not present in the PET scan area, the med likely would not have been scanned regardless what it was.

The rest of my comments are on the thread in the Nursing News forum from earlier in the day.

Tenebrae, BSN, RN

Specializes in Mental Health, Gerontology, Palliative. Has 9 years experience.

The nurse made an EGREGIOUS error that cost a patient her life.

We have MIMS in all our drug rooms, and if we dont have one of those, we have a "injectable meds" book

The nurse if she didnt know what the medication should have looked it up. If she didnt have a drug reference book, or any other written documentation she could have rung pharmacy

But if the only solution is to remove the nurse from the equation then we've lost an opportunity to improve. There's lessons to be learned.

What if Vanderbilt had protocols in place around administering conscious sedation? Such as training to include patient monitoring.

A supposedly prestigious hospital like Vanderbilt doesn't have protocols in place for administering conscious sedation?

Any hospital worth its weight should have protocols for administering conscious sedation.

Heck, I worked in an outpatient fertility clinic, administering conscious sedation for women undergoing eg harvesting that had protocols around administering conscious sedation including full set of obs on induction, and monitoring regularly throughout the procedure.

What if the ICU nurse who delegated this task to the "help all nurse" followed the proper rights of delegation? (right task to right person)
By all means this thing was a series of mistakes that ended up in a royal screw up that cost a patient their life.

Whats sadder is that most likely the whole thing could have been preventable

CalicoKitty, BSN, RN

Specializes in Med-Surg, Geriatrics, Wound Care. Has 9 years experience.

This case just makes me glad for scanning. I've accidentally pulled the wrong medication more than once (pulling from the "count" number versus the "drawer" number), and only caught it by scanning the medications. I've even almost given a patient a wrong medication because pharmacy loaded the similar named tablets into the drawer - had the patient not said "those aren't the pills I normally take", I would have ticked the override for them. When I was orienting, a doctor ordered a fluid, and my preceptor told me to start the fluid, but the doctor put an order in for another (LR vs NS) - not a huge mistake, but I really didn't like being pushed into starting a medication without scanning it (no, it wasn't emergent).

I know very little about versed and way less about verconium (I'm a med-surg nurse that has nothing to do with sedation), but in my mind, I'd think of versed as being a strong ativan (really, I don't know).

I can't remember if I've given medications without scanning them in procedure areas (dialysis or MRI), but it is possible. I know during codes, I don't always scan them, and at the end of the code pass them off to the "responsible" nurse. That seems to be what happened here. The nurse pulled the VE drug, read the dilution, administered the mg, gave the remaining medication to the primary nurse who saw the mistake 15 minutes later.

It was some dumb mistakes that I'm sure everyone has done at least some portion of once or twice. Luckily, most of those thoughtless actions don't end up with a deceased patient. As for the monitoring a patient after dosing, I don't administer those meds, so I'm not familiar with the expectation (I know that nurse was ICU trained, but perhaps she figured the patient was being monitored by everyone in PET).

/username, BSN, RN

Specializes in Critical Care.

I wonder if there was bar code scanning capability in the PET scan room

Procedural areas almost never scan meds for two main reasons: 1:1 nursing care at all times, and no possibility that you have the wrong patient after you confirm their identity upon arrival and time out, and their ID band is usually covered by some kind of sterile field.

This case just makes me glad for scanning. I've accidentally pulled the wrong medication more than once (pulling from the "count" number versus the "drawer" number), and only caught it by scanning the medications. I've even almost given a patient a wrong medication because pharmacy loaded the similar named tablets into the drawer - had the patient not said "those aren't the pills I normally take", I would have ticked the override for them. When I was orienting, a doctor ordered a fluid, and my preceptor told me to start the fluid, but the doctor put an order in for another (LR vs NS) - not a huge mistake, but I really didn't like being pushed into starting a medication without scanning it (no, it wasn't emergent).

CalicoKitty, these ^ examples are kinda scary in a way that would tell me I need to tighten up my practices. Let this be a reminder to remove/obtain medications conscientiously as if there were no scanning. That's the one surefire thing that would've prevented the error that is the subject of this discussion.

Scanning should never be considered anything more than a double-check. There's no good excuse for making it to a patient's bedside with a med that is not the ordered med. Scanning is a process that should be merely confirming correct information that you already know.

I understand what you mean when you say the case makes you glad for scanning, but I would suggest instead that we all should have the sh*t scared out of us the day that scanning actually prevents anything. Immediate personal corrective measures are indicated.

3ringnursing, BSN

Specializes in ICU; Telephone Triage Nurse. Has 25 years experience.

What a frightening way to die.

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.

missmollie, ADN, BSN, RN

Specializes in Neuroscience. Has 4 years experience.

I have some knowledge of this hospital because I have been there numerous times to investigate sentinel events very much like this. There are mistakes made at this very large hospital complex and I have substantiated several of them.

Please read the 2567 to obtain more details so you will know.

Just how many sentinel events does Vanderbilt have?

Here.I.Stand, BSN, RN

Specializes in SICU, trauma, neuro. Has 16 years experience.

I'm sure the nurse is beyond-words devastated over this....

But it's nursing school 100... one of the VERY first things a nursing student learns is the 5-7 rights of med administration!!

What the actual what?? Yes I understand things don't happen in a vacuum, but I'm sorry ... the RN -- the last line of defense -- didn't check the **** vial. S/he was negligent.

We are never SO busy that the

Conversely, her/his negligence cost a person's LIFE. The pt who depended on professionals' safe practices.... and who must have suffered indescribable agony and terror for several minutes before the end.

Here.I.Stand, BSN, RN

Specializes in SICU, trauma, neuro. Has 16 years experience.

CalicoKitty[/Quote] nearly 8 years as an ICU RN here.. Both hospitals I've been at require the RN to stay with the pt. The rad techs can do BLS sure... but they can't assess and interpret VS, they aren't trained in assessing a pt's response to meds, they are not trained in airway management (to my knowledge anyway)..

If we are so much as transferring a stable pt to a tele-monitored floor, the RN must accompany the pt.

Here.I.Stand, BSN, RN

Specializes in SICU, trauma, neuro. Has 16 years experience.

To play the devil's advocate, in my PICU setting we override and give paralytics all of the time; we'd be in a real bind if paralytics came from pharmacy only, as our peds cardiac patients have a tendency to flip out, bear down, have pulmonary hypertensive crises, and actively try to die within about a 2-minute span. I'd say that on a weekly basis, we have to give paralytics (plus sedation) at a moment's notice to combat pulmonary hypertension and prevent codes; granted, many of our patient's requiring paralytics have a standing PRN paralytic ordered, and they're obviously all intubated...

That makes sense for emergent situations, and we do it in the adult world e.g. for emergent RSIs or internally decapitated pt trying to move... but this wasn't even almost an emergency. :(

Here.I.Stand, BSN, RN

Specializes in SICU, trauma, neuro. Has 16 years experience.

This wasn't an isolated med error. Most of us have made one of those. This was a major practice error made by a nurse who clearly didn't have the sense God gave a cardboard box[/Quote]

Best quote in my recent memory!

I was going to say too, I'm typically not one to string up a nurse over a med error. We've all made errors. But accidentally giving an extra Colace is a faaaaar cry from pushing Vec.