Reminder why the seven rights are important

[Triddin]

Vandy patient dies after nurse gives lethal dose of wrong drug; puts Medicare at risk - NewsChannel 5 Nashville

I'm curious why the hospital didn't report the error

[JKL33]

The two statements referencing death row/lethal injection are inflammatory/sensationalized and absolutely idiotic. Beyond the pale.

[Sour Lemon]

The two statements referencing death row/lethal injection are inflammatory/sensationalized and absolutely idiotic. Beyond the pale.

I thought it was bizarre that the article ended and began emphasizing medicaid reimbursement issues.

[EllaBella1, BSN]

I do agree that the lethal injection bit was sensationalized. But it's interesting that the Pyxis allowed the nurse to override Vecuronium by name. I'm used to most paralytics being locked in high alert areas in the Pyxis or in a RSI kit. Is that not the case at all hospitals?

[CalicoKitty, BSN, MSN, RN]

I do agree that the lethal injection bit was sensationalized. But it's interesting that the Pyxis allowed the nurse to override Vecuronium by name. I'm used to most paralytics being locked in high alert areas in the Pyxis or in a RSI kit. Is that not the case at all hospitals?

At my hospital, in the ER and some procedure areas, all of the medications in the may be Pyxis are available. It isn't really an override, you just pull what was ordered (it doesn't tell you what was ordered, so if you get 650 tylenol instead of 1000, gotta go back). BUT, the medication should still be scanned before administration - with slight chances for emergencies. If the patient is well enough to say they are claustrophobic, then the nurse should have been able to spare that 30 seconds to scan the med before administration - which would have picked it up as being the wrong med.

[Lunah, MSN, RN]

The two statements referencing death row/lethal injection are inflammatory/sensationalized and absolutely idiotic. Beyond the pale.

I was like, who wrote this??? Oh, a news channel. SENSATIONAL!

[Medic_to_BSN, BSN, RN]

I found this story bizarre. I know that at some point, almost everyone will make a medication error. But it seems more than a little odd that this one occurred from selecting "the first medication" from a two-letter input, especially given that midazolam "VErsed" (vs. VErcuronium) is a controlled substance, requiring (I would presume) some expected additional paperwork - at least I would think the nurse would have been expecting that. (I'm not assigning blame - obviously, it's not like we have the complete story from a short article).

By this logic, ALtretamine could be selected instead of ALprazolam, or VAltrex instead of VAlium (since they were mixing brand names and generic names for the search to produce both), etc.

And, yes, the references to execution drugs sure seemed to be gratuitous editorializing or simply irrelevant.

[psu_213, BSN, RN]

The two statements referencing death row/lethal injection are inflammatory/sensationalized and absolutely idiotic. Beyond the pale.

And in other news: "a nurse gave medication that is frequently used to commit suicide. That medicine is called acetaminophen."

[Medic_to_BSN, BSN, RN]

And in other news: "a nurse gave medication that is frequently used to commit suicide. That medicine is called acetaminophen."

Don't forget the arsonist ... er, nurse, ... supplying oxygen, which also feeds raging wild fires! haha

[twinsmom788]

Vandy patient dies after nurse gives lethal dose of wrong drug; puts Medicare at risk - NewsChannel 5 Nashville

I'm curious why the hospital didn't report the error

If Vandy did not report the serious error, then the Tennessee Department of Health most likely sent surveyors in to conduct an investigation as a result of a complaint received.This is not the first time this type of situation has occurred. I personally have investigated serious issues at Vandy multiple times.

The reason the CMS issue is newsworthy, is because, the state/CMS requires that cases of serious Immediate Jeopardy ( life threatening patient care issues) which can shut down admissions to the hospital or nursing home are published in the newspaper and broadcast in the media.

[JKL33]

But it seems more than a little odd that this one occurred from selecting "the first medication" from a two-letter input, especially given that midazolam "VErsed" (vs. VErcuronium) is a controlled substance, requiring (I would presume) some expected additional paperwork - at least I would think the nurse would have been expecting that.

It is completely possible, though. Once you override, you're able to do just what is described if the system isn't programmed to ask for a 2nd nurse to obtain a medication via override. If it only requires one nurse, you enter the override program, type, select. Drawer pops open. There's no paperwork - - we administer CSs all day long; if you don't scan then you have nothing stopping you. (*And in fairness, there is a fair amount of no scanning in dire emergencies/scanning after the fact. Won't comment on the emergent vs. non-emergent aspect).

The one curiosity for me is the fact that vecuronium is a powder IME. Has to be reconstituted. Kind of a tip-off that something isn't right.

I find this sad overall, so that's all I have to say.

[Anonymous865]

The Tennessean has a more thorough report of what happened.

Vanderbilt nurse's error with vecuronium not reported to medical examiner

"it appears that a Vanderbilt doctor told the medical examiner's office that the patient died from bleeding and that any medication errors were purely "hearsay," according to the investigation report. This led the medical examiner's office to decline to investigate because staff believed the patient died a natural death that was outside their investigatory jurisdiction."