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Nurse Gives Lethal Dose of Vecuronium Instead of Versed

Nurses Article   (234,873 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 4 of Nurse Gives Lethal Dose of Vecuronium Instead of Versed. If you want to start from the beginning Go to First Page.

Jory has 10 years experience as a MSN, APRN, CNM.

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Maybe it's just me but I see something far more simple.

The nurse pulled a drug that was clearly not the one she was searching for. This wasn't even a case of a similar sounding drug. This was a nurse that tried to find versed, couldn't, and then thought close enough was good enough.

This is an error most new grad nurses wouldn't make.

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kat7464 has 5+ years experience and works as a Hospice Nurse.

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Best advice I was ever given came in nursing school - always ask yourself, "Does this make sense?" before doing anything to the patient. This made no sense on many levels and the nurse should have stopped in her tracks before administering that drug.

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"Either things in Vanderbilt are run by a group of recent Acute Psych unit escapees, or I do not know."

"Or I do not know" That is correct. You don't know. Trust me, Vandy is run by a expert and knowledgeable group of physicians and nurses. My daughters have both worked there in the summer between their third and fourth year of med school.

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.

It is good to know more about the facility. It does seem there was issues from protocol and job description down to the nurse's incompetence here that all played a role in this. It seems like a "perfect storm" so to speak

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blondy2061h has 9 years experience as a MSN, RN and works as a Nurse, duh!.

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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.

 

The RN may be the last line of defense, but by overriding the med she went ahead and bypassed ever other line of defense and made herself the only live off defense.

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blondy2061h has 9 years experience as a MSN, RN and works as a Nurse, duh!.

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Best advice I was ever given came in nursing school - always ask yourself, "Does this make sense?" before doing anything to the patient. This made no sense on many levels and the nurse should have stopped in her tracks before administering that drug.

They clearly didn't know enough about vec of versed to know if it made sense

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

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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. END QUOTE

You are correct, thanks for the clarification. Conscious sedation is not defined by the drug, but by the pt's response as to whether it's anxiolytic, moderate, deep or general anesthesia.

CMS cited Vanderbilt for not having monitoring requirements (monitor for hypoventilation, for example) in their high alert medication policy, which included Versed.

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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.

Using the Five Rights for three checks before administering is a big part of preventing medication errors, as is having good knowledge of the medication, i.e., indications for giving, action, expected effects, side effects, contraindications, adverse effects and action to take, monitoring necessary, assessment before/after administering, pertinent lab values, precautions to take, etc. Barcode technology doesn't eliminate the need for these essential safety checks.

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CMS cited Vanderbilt for not having monitoring requirements (monitor for hypoventilation, for example) in their high alert medication policy, which included Versed.

Although there is apparently evidence to support this citation I find it very difficult to believe that a tertiary center such as Vanderbilt would flaunt standards that even the smallest hospitals have had in place for years.

Regardless of the lack of policy this nurse should have never administered a medication she was unfamiliar with. Anybody who has given this drug (Versed) knows it comes with a risk of hypoventilation and would monitor for it. If she had done the bare minimum for Versed the patient would not have died from the accidental Vecuronium. The cavalier choices she made (it starts with Ve, oh well close enough) should not be blamed on the hospital. Don't get me wrong I am a huge supporter of not blaming nurses for system failures and human error but this goes waaaayyyy beyond that. Frankly, calling this a "mistake" is a misnomer. She made bad, bad, inexcusable choices that resulted in the death of another human. I'm sure she's devastated. She should be. I understand the need for a non-punitive environment when it comes to med errors but jeebus we have to draw the line somewhere.

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

333 Likes; 10 Followers; 81 Articles; 224,777 Visitors; 1,685 Posts

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 see two two and only two issues here. The nurse was shockingly incompetent and the Pyxis system should not have allowed an override of such a dangerous drug.

The patient was doing well and what was ordered was a full body PET scan. I agree with several providers who questioned the necessity. Just provides the context and background decisions that led up to the event, which is helpful in an RCA. In outpatient, they probably would have given a po anxiolytic, not IV Versed. Of course the key factors are the nurse's actions and negligence.

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563 Likes; 3 Followers; 25,917 Visitors; 5,221 Posts

Horrible tragedy and mindblowing negligence by RN and puzzling lack of monitoring protocols to begin with, even if appropriate drug/dose given.

And may I also add that KatieMi is a rock star. :)

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klone has 13 years experience as a MSN, RN and works as a Director of OB Services.

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I have nothing to add, other than saying how humbled I am at how ******* smart my Allnurses colleagues are! You guys always keep me learning.

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blondy2061h has 9 years experience as a MSN, RN and works as a Nurse, duh!.

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I just got done reading the 56 page CMS report and I have a lot more questions than when I started.

The nurse got the vecoronium out of the neuro ICU pyxis, where the patient was an inpatient. That explains how she had access to it. The bin was labelled as a paralytic that causes respiratory arrest.

She's not sure how much she gave. Maybe 1ml or 1mg.

She brought it down reconstituted in a baggie, gave it to the patient in a holding area. It was only when she gave the excess medication to the patient's primary nurse after the patient was brought back to ICU after the code that the primary nurse noticed it was vec.

The patient was left with just the tech, unmonitored, in a room waiting to go into the scan. Never made it into the scan. This is a patient that came from an ICU and was step down status. These patients are always on monitor at my facility and are transported by an RN, not transport as described in the CMS report. Further in the report it says she was awaiting a floor bed, so that explains this.

The RN was talking to the patient's family when she heard the code called in PET scan. She called PET scan not once but twice to see if it was her patient. She didn't get an answer. Calling an area during a code blue? How lacking in judgement is this person?

She did indeed get fired.

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