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Nurse Gives Lethal Dose of Vecuronium Instead of Versed

Nurses Article   (235,568 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 6 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.

366 Likes; 10 Followers; 82 Articles; 224,989 Visitors; 1,696 Posts

What if there was a way for someone who had not been adequately trained to insist on that training or refuse to go on the floor unsafe, without getting fired?

On the one hand, nurses are told to refuse unsafe assignments..... but in reality the pressure is to comply.

I've seen MedSurg nurses floated to Telemetry who do not know what they do not know and shouldn't be caring for Tele patients.

If they refuse, they are at risk for everything from not being considered a team player to being scorned to being fired.

Edited by Nurse Beth

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SobreRN works as a RN.

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

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.

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)

What if there was not a culture of expediency, to get the job done at all costs, and hurry up? What if the procedure had been rescheduled while the pt given po anxiolytic? Btw, I've seen GI docs push assistants to shorten the cleaning time for scopes. And the overwhelmed assistants complied.

What if there was a clear job description with qualifications and training for the "help all nurse"?

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

Spot on! I grew to loathe techs until I came to conclusion that someone was pressuring them to get er done stat for non-emergent situations. I believe I cited this as one of the factors in deciding I no longer do floor nursing. When I did one would think I could throw wings on and fly the patient 4 stories down for a CT/MRI/PET etc...what was the big rush on this PET for?

That and I am surprised that anyone pushing versed would not know generic name? I worked many years in oncology; needed chemo cert but not ACLS, I did not push versed until years into my career + adding ACLS.

That was some time ago, do not recall even pushing morphine on an opiate-naive patient without monitoring them.

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30 Visitors; 1 Post

I have not done hospital nursing for 20 years so the PXIS system is not something I am familiar with. My comment is if this patient was an ICU patient why was she left alone in an Xray area and if she was elderly wasn't she a fall risk. Why would anyone have left her alone? This is basic nursing to me...

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KatieMI has 6 years experience as a BSN, MSN and works as a Internal Medicine.

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

Spot on! I grew to loathe techs until I came to conclusion that someone was pressuring them to get er done stat for non-emergent situations. I believe I cited this as one of the factors in deciding I no longer do floor nursing. When I did one would think I could throw wings on and fly the patient 4 stories down for a CT/MRI/PET etc...what was the big rush on this PET for?

That and I am surprised that anyone pushing versed would not know generic name? I worked many years in oncology; needed chemo cert but not ACLS, I did not push versed until years into my career + adding ACLS.

That was some time ago, do not recall even pushing morphine on an opiate-naive patient without monitoring them.

Re. rush to get things done, that's because not only RNs are suffering from a disease named "being task oriented". Unit secretaries, techs, schedulers and even quite a few physicians are obcessed with getting as many studies, analyses, diagnostics, calls, contacts, conferences, etc., etc. DONE. The constant whirlwind of activity justifies inpatient stay (thus providing $$$$$ for facility), it impresses "customers" and "patrons" (sorry, I mean patients and families), produces something to do for everybody and, overall assures full time employment and benefits for me and everybody else here.

I have no idea why they decided to do full body PET. This thing most commonly ordered for onco staging. But in academic institutions things tend to go in overdrive just because of possibilities on hand.

Overall, my opinion is: one can do as many root case analysis as he wants, and write as many policies and schmolicies as he dreams of, but it all will lead to nothing or worse till every. single. person. dealing with patients gets two things:

- knowledge,

and

- common sense.

Even providing the nurse in question had no idea about Versed, it was plain simple common sense not to adminuster a drug she had no idea about. If nothing at all else, she could go to restroom and quickly Google "versed" while peeing and get at least the part of picture saying that patient must be baseline monitored after administration. It was also a simple common sense not to leave a patient who was in gray area between ICU and floor alone with no monitors and no one near except camera.

I transported patients to all kinds of scans and studies gazillion of times, and at no time I could leave them even to go pee or get some water. I had to sit in control room while they were on scan and watch monitor which was strategically placed so it could be seen. I knew where IR kept stuff, what they could do and what they couldn't. I was ready to run a code should something happen, and, should it happen, I would take over imaging suite techs, direct their actions and run it till code team get in.

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Ruby Vee has 40 years experience as a BSN.

942 Likes; 11 Followers; 64 Articles; 168,848 Visitors; 13,727 Posts

What a tragic event! There was a whole series of errors made, some of them by the nurse who administered the drug. But hers wasn't the only mistake that contributed to the horrible outcome. Since we all make mistakes, I would hope to see some empathy for this poor nurse who is probably beating herself up over the event.

Some systems changes are obviously needed. Who was supposed to be monitoring the patient, and why weren't they aware of the patient's condition? Was anyone monitoring the O2 saturations? Or is this a case where the test was considered more important than the patient -- which I have seen. (Medical resident wanted imaging which had to be done in the department. Transport team was tied up, and patient's nurse had other patients and could not leave the floor. Medical resident and medical student took it upon themselves to take patient to the test and to "watch her" during the test. When patient was returned to the nursing unit by Medical resident and medical student, she was dead. Neither had any idea when she was last seen alive, but each thought the other was watching her -- and both were instead entranced with the test.)

I sincerely hope that the nurses involved are getting some help, some empathy and some compassion.

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10 Visitors; 1 Post

There's no doubt that the nurse involved in this is punishing herself more than anyone else could. We all make mistakes. That being said...there are a number of takeaways from this. 1., be a self advocate. Ask. If you aren't familiar with a med, don't be afraid to get help. 2., always, always, always double check the med, even if it is something you have given a hundred times before. It can't hurt and might save a life. 3., if you are an administrator, remember that nursing is not one size fits all. Most nurses are specialized. As an L&D nurse, I would not ever work in the ICU. Respect the limitations and expertise of each nurse. 4., the bottom line here is that the nurse didn't know the med and made a fatal error. We all need to learn from this.

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RainMom has 7 years experience.

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Is it common for an electronic medication system to use generic names sometimes and brand names other times? Could that be something to correct?

Meds in our pyxis can be searched by both the generic & brandname; it will pop up whichever way you search.

What a terrible way to die. Doesn't happen often but some of the scariest moments for me in PACU have been realizing that my fresh surgical pt did not get enough reversal agent for the paralytic. They get very "floppy", can't tell you what's wrong, look like a fish out of water gulping for air & usually need bagged until more reversal is given.

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aprilmoss has 20 years experience and works as a School Nurse.

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Here's a (presumably) working link to the report.

https://bloximages.newyork1.vip.townnews.com/wsmv.com/content/tncms/assets/v3/editorial/a/7e/a7ea6b5e-f41f-11e8-af7b-570ec9f22209/5c005d6899b8d.pdf.pdf

To make matters worse, the doctors at Vandy didn't properly report the death (covering it up, albeit unsuccessfully).

Edited by aprilmoss

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Luchador has 5 years experience as a CNA, EMT-B.

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First semester RN student here. We had a simulation/test with a Pyxis. If we didn't check the med 3 times (1) when you get it out (2) when you draw it/mix it/ pour it, and (3) right before you push it--- you flunked.

And they tried to trick us. Had a patient with the wrong wrist band for some students. The pyxis straight up dispersed the wrong med for other students. For others there was an order to give something they were allergic to and so on.

As others have pointed out, this is Nursing 101--- literally.

Edited by Luchador

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hawaiicarl has 28 years experience as a BSN, RN and works as a Charge Nurse.

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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.

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

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Luchador has 5 years experience as a CNA, EMT-B.

118 Likes; 1,241 Visitors; 176 Posts

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

Here you go

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Lorie Brown RN, MN, JD has 30 years experience and works as a Nurse Attorney.

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Great post. I represented a nurse who was floated to the ER. She never worked there and had no experience. She expressed her concern but management insisted she go. A similar mistake happened but fortunately, the patient did not die. No wonder why there are over 100,000 unnecessary deaths in hospitals each year. Nurses are overworked and are bombarded with new information every few minutes.

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