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Nurse Gives Lethal Dose of Vecuronium Instead of Versed

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

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

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She only gave 2 mg of Vec, they have the rest of the med in the syringe, which is a very small dose.

2 mg vec was way below loading and truly lethal dose. But we do not know so many details.

People usually do not have intraparenhymal brain bleeds just out of the blue sky. An elderly, already weakened and likely with some degree of parenchymal organ damage patient (HTN, afib - and that's only what the record states, there can be some more preexisting medical conditions) could get just weak a little more, and that would be enough for her to be sent into retaining CO2, respiratory acidosis and secondary arrest within those 30 min.

It was stated she was "alert and oriented" and "doing good" enough for floor transfer, but it doesn't mean she was in good shape. We all saw patients who were totally there and listed as "stable" condition and still approximately as active and strong as a jelly fish on sandy beach. When such people start to go south for literally whatever reason, they do it QUICK. It is ridiculous how low their reserves can be and how little required to move them from their "usual" state of health to the brink of dying.

Plus, we still have no idea why doctors wanted her to get that whole body PET scan. From the fact that she had intraparenhymal brain bleed as admission to ICU diagnosis, one educated (although, I admit, far-cry) guess would be DDx of "active" brain met or/ vs. glioblastoma multiforme. Both frequently manifest with intraparenchymal brain bleed, both are quickly "treated" symptomatically so patient "starts to improve" and can be transferred to floor (in just 2 days - admitted 12/24, the event took place 12/26) and workup for both typically involve that whole body PET scan.

Edited by KatieMI

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2 mg vec was way below loading and truly lethal dose. But we do not know so many details.

And the "truly lethal dose" of vecuronium would be what, exactly?

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

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And the "truly lethal dose" of vecuronium would be what, exactly?

0.08 - 0.1 mg/kg. Or approximately 1 standard reconstituted vial of 10 mg for anyone weighting 70 to 100 kg (165 to 220 lbs). Full paralysis in 3 to 5 min with impossibility to breathe without mechanical support of ventilation of some kind, then death from hypoxia in 3 to 5 min more.

BTW, cause of death would be "hypoxia", "respiratory failure", "anoxic brain damage" or something like this but not "vecuronium poisoning". Paralyzing agents are absolutely safe in terms of they do not kill like cyanides. Their expected effect is what causes death if patient is not helped to breathe till their action is over.

Edited by KatieMI

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0.08 - 0.1 mg/kg. Or approximately 1 standard reconstituted vial of 10 mg for anyone weighting 70 to 100 kg (170 to 220 lbs). Full paralysis in 3 to 5 min with impossibility to breathe without mechanical support of some kind, then death from hypoxia in 3 to 5 min more.

And for elderly patients, with significant co-morbidities and previous medical history? They would be more sensitive to lower doses of the medication.

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

207 Likes; 40,753 Visitors; 2,321 Posts

And for elderly patients, with significant co-morbidities and previous medical history? They would be more sensitive to lower doses of the medication.

That's what I wrote in one of my previous messages.

Although for vec there are only two main factors: total muscle mass and really, really low renal function (main metabolite is renally excreted and has 80% activity).

Of both we know nothing with the info we have.

And we do not even know how much of the vec was actually given, for sure.

But from the fact that the patient came back to ROSC after only "two or three" cycles of CPR it can be concluded that the dose was only enough to weaken the patient and let her slowly collect CO2 for like 20-25 min. So, for whatever, it shouldn't be a full vial. Should she get "near-intubation" dose, she must be dead in those 25 min with zero recovery.

Edited by KatieMI

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Even as a nursing student, I knew the difference between vecuronium and versed!!! This nurse was beyond negligent and should have her license taken away and involuntary manslaughter charges should be pressed. This is unacceptable practice that resulted in a horrifying death for a patient that should never, ever have happened! I am sickened by this.

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Megan1977 has 38 years experience as a MSN, RN.

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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

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 nurse omitted 4 of the 7 rights of medication administration. And while training another nurse to boot. And she ignored all of the warnings on the Pyxis as well as on the vial. Just disregarded them. Furthermore no patient receiving Versed should be left un-monitored. Even if it's just eyes-on. No nurse in their right mind would administer such a medication and then walk away. There simply is NO excuse for that. None! That she administered Vecuronium instead of Versed actually has little to do with it. Certainly not 2mg of it. If she had monitored the patient properly even that accidental dose of Vec wouldn't have killed the patient. She would have seen what was happening and intervened. The patient could have just as well died from the Versed. 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. I'm all for using these situations as teaching moments but come on. We need to call it what it is. A nurse with a huge knowledge deficit doing a job she was ill-equipped to do and who demonstrated a shocking lack of basic good judgement.

Combine that with...

A machine that should never have been programmed to allow an override for such a dangerous med. Ours are programmed only to allow override for things like NS, D50, Epi ampules. No narcs, benzos and most definitely not paralytics.

I agree with Katie.

I agree with this ^^^ 100%- the nurses involved have a huge knowledge deficit and lack common sense. I am going to use this as a case study for my students

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Sour Lemon has 9 years experience.

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Anyone else wondering about the girl in the stock photo? Probably not.

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MunoRN has 10 years experience and works as a Critical Care.

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She only gave 2 mg of Vec, they have the rest of the med in the syringe, which is a very small dose.

From the description, it sounds as though half the vial was given, (what the nurse thought was 1mg of midazolam), which would have 5mg of a typical 10mg vial, which is a normal dose to induce paralysis for someone of 'typical' weight.

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MunoRN has 10 years experience and works as a Critical Care.

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While there was clearly a major failure of practice by the nurse who pulled and gave the vecuronium, there were also clear systemic failures that otherwise should have prevented serious harm from that error. The rad tech called the imaging department RN and told them that the patient would require sedation, that RN told the rad tech that they couldn't have sedation because then they would need to be monitored, which should have prompted a call by the imaging RN to the patient's primary RN, but instead the rad tech told the primary RN that they couldn't do the scan, so the primary RN said they would see to it that the patient was given an anxiolytic but that the patient wouldn't be monitored, which should have prompted the rad tech to inform the imaging RN of the situation. This is also a good example of why ISMP has been recommending against the use of medication trade names in hospitals for a while now, I've worked in a couple places where no order using trade names is considered valid in order to break the habit. And on top of all that, there was no apparent valid indication for a full body PET scan, and the patient was apparently given the midazolam an hour before the scan was expected to start, which would have mostly worn off by the that time.

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

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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

When you have such a big institution you're going to have more events than the average place even if your percentage is much better than average.

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

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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.

But if the option is a nurse with no ER experience or no extra nurse at all, I'll take the one with no ER experience. I won't expect them to function independently, but they can be delegated to by other nurses. Hopefully there are some tasks they know how to safely do- drawing labs, starting IVs, taking vitals, hanging IV antibiotics, giving pills, helping transport people, etc.

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