blondy2061h MSN, RN

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.

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.

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.

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

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.

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.

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.

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

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.

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?

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.

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.

That's punishment. A mask isn't. A mask is PPE.

I have idiopathic intracranial hypertension also and an NSAID allergy, so yeah, that's my life.

Sounds like you probably had a lot of patients with very poorly managed pain. Yikes.