blondy2061h MSN, RN

blondy2061h has 15 years experience as a MSN, RN and specializes in Oncology.

blondy2061h's Latest Activity

1. 

   Nurse Gives Lethal Dose of Vecuronium Instead of Versed

   blondy2061h replied to Nurse Beth's topic in Nursing

   It's a good point. A nurse I work with made an extremely similar error, but the med they gave instead of the ordered med was not one with life threatening side effects so no viral news story there.
2. 

   Nurse Gives Lethal Dose of Vecuronium Instead of Versed

   blondy2061h replied to Nurse Beth's topic in Nursing

   They don't know how much was given. The CMS report makes that very clear. There were two syringes with different amounts of liquid. They weren't able to determine what was in each one. The nurse was very non-committal to what dose she gave. To me that means she really was totally clueless or she was being dodgy. I get that this happened a year ago, but I made a serious med error 7 years ago and remember everything about it.
3. 

   Nurse Gives Lethal Dose of Vecuronium Instead of Versed

   blondy2061h replied to Nurse Beth's topic in Nursing

   I was initially confused at how an ICU patient ended up off the unit without an ICU nurse or monitor, but it seems the patient was awaiting a floor bed. That then makes me confused why they jumped to IV versed for a PET scan. Seems like PO Xanax would have been a more appropriate starting point, but obviously I don't know the patient.
4. 

   Nurse Gives Lethal Dose of Vecuronium Instead of Versed

   blondy2061h replied to Nurse Beth's topic in Nursing

   Oh I do suspect she'll never be a nurse again
5. 

   Nurse Gives Lethal Dose of Vecuronium Instead of Versed

   blondy2061h replied to Nurse Beth's topic in Nursing

   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.
6. 

   Nurse Gives Lethal Dose of Vecuronium Instead of Versed

   blondy2061h replied to Nurse Beth's topic in Nursing

   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.
7. 

   Nurse Gives Lethal Dose of Vecuronium Instead of Versed

   blondy2061h replied to Nurse Beth's topic in Nursing

   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.
8. 

   Nurse Gives Lethal Dose of Vecuronium Instead of Versed

   blondy2061h replied to Nurse Beth's topic in Nursing

   They clearly didn't know enough about vec of versed to know if it made sense
9. 

   Nurse Gives Lethal Dose of Vecuronium Instead of Versed

   blondy2061h replied to Nurse Beth's topic in Nursing

   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.
10. 

    Nurse Gives Lethal Dose of Vecuronium Instead of Versed

    blondy2061h replied to Nurse Beth's topic in Nursing

    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?
11. 

    Nurse Gives Lethal Dose of Vecuronium Instead of Versed

    blondy2061h replied to Nurse Beth's topic in Nursing

    This is what I don't understand about the timeline. 30 minutes since she got the vec when the code was called and they got her back with 2 rounds of acls? But she was so hypoxic she was declared brain dead within 24 hours? As far as job descriptions go she probably had a general RN job description but specific to the helper role.
12. 

    Pain Management & the Opioid Crisis - AACN-NTI

    blondy2061h replied to allnurses's topic in Nursing

    I feel like "opiod epidemic" had just become such a trendy catch phrase with half the people using it having no idea what they're talking about our why they're using it in the context of patients who really are looking for pain relief. We used to talk about "pain is the 6th vital sign" and "pain is what the patient says." Now God help you if you have pain without a clear visible cause.
13. 

    Case Study: Can You Prevent This Medical Error?

    blondy2061h replied to SafetyNurse1968's topic in Critical

    Thank you so much for sharing this and taking steps to prevent it from happening again!
14. 

    Case Study: Can You Prevent This Medical Error?

    blondy2061h replied to SafetyNurse1968's topic in Critical

    It's good for a student to get good habits, too, I guess. Then become more efficient later.
15. 

    Case Study: Can You Prevent This Medical Error?

    blondy2061h replied to SafetyNurse1968's topic in Critical

    That checklist for the student nurses is almost hilarious when you think that it's not uncommon in my area for some nurses to have 16 patients on night shift and not unheard of for patients to have meds due every 2 hours. That just isn't happening. So short cuts happen. Yes, better staffing would help. But in the meantime it's better to make a more realistic algorithm that can actually be followed so short cuts aren't necessary.
16. 

    Is it wrong to start infusion that will not finish till next shift?

    blondy2061h replied to Capp's topic in Medications

    Sorry Sir, my shift is over so I'm going to have to discontinue your IV and Suzzy will be in in about an hour to try and start a new IV for her shift.