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

[emmjayy, BSN, RN]

I work in an ICU and over-ride the med cabinet very frequently when emergencies are going on. I know my meds well enough to know that a bottle of Versed looks very different from a bottle of Vecuronium. I honestly find it pretty tough to make excuses for this nurse, as it doesn't even sound like this was an emergency situation where adrenaline is running high and there's pressure to hustle with the med. I am usually the last person to hop on the nurse-blaming band-wagon because I know horrible things happen, mistakes get made, and it's not typically reflective of the nurse's competency. In this case, however, I can't help but wonder what on earth was going through this nurse's head.

[JKL33]

Well, this source has posted the CMS investigatory report.

Overall nauseating.

Without disregarding the "5 Rights" error, this (nursing/safety community) discussion leaves much to be desired, and frankly IMO V's accusations and statements to CMS betray hospitals' utter refusal to look at themselves. There are major factors (*major*) factors barely mentioned; mentioned only in passing.

Again, without defending the failure to complete 5 Rights, here are a few other (reported) facts I picked up from the report:

*V had instituted "World's Best Performance-Timing-and-Statistic-Producing EMR" within the month prior to this event. If you have ever been through this at an institution the size of V, you know why it is significant. [beside the point and irrelevant "fun fact": There's no way a system this size spends less than $billion(s) on acquiring and rolling out across the system.]

*The nurse was performing a roving/"help-all" role. S/he was asked to go to a completely different area and medicate someone else's patient, which was to be accomplished prior to (or on the way to) going to a second completely different area to do something for another patient. **Now she is accused of failing to monitor the patient in PET scan after giving the med. This is an important take-home point for every nurse who could ever find themselves doing things like this as part of teamwork or helping others. Raise your hand if you have ever gone somewhere to medicate someone else's patient (I have). Raise your hand if you were relieved of all of your other duties/expectations so that you could stay put in a different department for an hour to monitor a stable patient after you administered a med. Right. It's not even an expectation. The mere idea of it is something that would be ridiculed as laziness or wanting to get out of work.

*The patient's actual primary nurse could not leave the department to go medicate her own patient because she was watching yet another nurse's patients - - that nurse was on lunch break.

*There was no med scanning ability in PET scan. Since at least two of the hospital representatives/officers discussed with CMS the "numerous"/"multiple" safety points the nurse supposedly bypassed, I think is fair game to note that, after years now of being patronizingly told how nurses' critical thinking is not adequate, and other (better) human beings working very hard on manipulating our environment in attempt to "decrease your need for critical thinking," there actually was no scanning technology present in that patient treatment area. My point is, if the usefulness of "old school" safety imperatives are downplayed or lost in confusion or in any other way minimized even though they are very much still relevant and live-saving, don't expect them to save the day when technology doesn't.

*Nothing at all mentions the experience level of the erring nurse. I bring this up only because of the lack of familiarity with the fact that vecuronium is powdered, midazolam is not, and the unfamiliarity with generic vs. brand names (the first thing you would search if "versed" didn't come up in an MDC list would be "midazolam"). Typically you would do that before considering an override. The person was performing in a roving role and orienting another nurse. It is not our right to know, and it wouldn't be an excuse anyway, but I think V is charged with reviewing these issues. It's awfully easy to just say that the nurse was not conscientious and bypassed all the "multiple" safety measures V had in place. I want (but have no right) to know whether the person's experience should have suggested that a precepting and roving role was appropriate.

Anyway, let the real safety discussion begin. As is almost always true, there is more that can be faulted than just one person.

[Lunah, MSN, RN]

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 said the same thing yesterday when talking about this with some other nurses! This is a med error that took real effort. Very strange.

[Lunah, MSN, RN]

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."

There are so many weird things, like the baggie. Why would there be a baggie with the med? Unless it had both the vial of vec and a vial for reconstituting together in a baggie in the Pyxis.

The article said the vec caused the patient to lose consciousness, though the patient was more likely conscious up to the point of becoming too hypoxic to remain conscious. Having had a cardiac MRI recently that required Valium for me to endure it, I cannot imagine how awful this must have been for this poor patient. I am just horrified, this was my biggest fear in the MRI - the feeling that I was unable to breathe and that I was going to suffocate. Ugh.

[JKL33]

I said the same thing yesterday when talking about this with some other nurses! This is a med error that took real effort. Very strange.

I know where you're coming from, but I see it a little differently (the following comments are in no way directed personally, Pixie): There is only one thing that could have stopped this cold that wasn't done, which was conscientiously looking at the label. People are in the habit of not doing that now because the usual practice has become scanning. Not looking at the vial isn't my MO, but I see it enough where the reason to really look at the label is if/when there is a problem with scanning. I see all of this as having happened in a setting of the usual and accepted chaos (constant change, new EMR, constantly orienting, "covering" others' patients, and floating all over the dang place being a good team member/keeping that bottom line efficient).

My interest in this is that I believe the benefits (or overall usefulness) of technology-related safety measures have been oversold or not kept in perspective while at the same time the reasons given for this have mainly been "look what happens when we rely on humans" (accompanied by examples that border on mockery and are very condescending). Well guess what. The bottom line here despite shameful billions spent, is still human beings - - but all we have done to enable best human functioning is tell people they're so fallible they can't and shouldn't be relied upon.

They're also blathering on (implied) about the fact that nurses shouldn't be able to access meds that haven't been verified by pharmacy. Well, that verification process is something that also once fell into nursing realm (it is largely accounted for in the "Rights") - - but we've long since been told we were not adequate to perform that, either, so all of that question-asking and evaluating that was done by a professional nurse as part of the medication administration process has gone by the wayside. I will argue anyone regarding my belief that hospitals' dumbing down of the RN role so that they can employ a revolving door of novices and their spreading of everyone as thin as possible matters overall - including in situations like these. Meanwhile, things that hospitals must do to enable safety is a conversation that has never been anything but disingenuous. For example: What is their contingency plan for a nurse being on break? Someone else who has their own assignment "watches" those patients. What is their contingency plan for a nurse who must leave the unit to administer a med to a patient off the unit and then monitor that patient according to professional nursing standards that CMS will refer to when they are investigating a death?>>> NONE. There is no plan or allowance for that. It is not efficient and therefore it is ignored.

I will go on record as being 100% "put up or shut up" with regard to safety. It is not acceptable to wring your hands and point fingers about what a professional nurse would/should do, when acute care nurses spend all of their time in a setting that flat out ignores and a good deal of time prevents RNs from easily accomplishing much of what a professional nurse should do.

[K9lover, ASN, RN]

Why the hyperbole in pointing out that these medications are used in death penalty cases when they are USUALLY not?

[K9lover, ASN, RN]

I agree, this has nothing to do with death row and that is not what the drugs are usually used for.

[Julius Seizure]

Well, this source has posted the CMS investigatory report.

*Nothing at all mentions the experience level of the erring nurse. I bring this up only because of the lack of familiarity with the fact that vecuronium is powdered, midazolam is not, and the unfamiliarity with generic vs. brand names (the first thing you would search if "versed" didn't come up in an MDC list would be "midazolam"). Typically you would do that before considering an override. The person was performing in a roving role and orienting another nurse. It is not our right to know, and it wouldn't be an excuse anyway, but I think V is charged with reviewing these issues. It's awfully easy to just say that the nurse was not conscientious and bypassed all the "multiple" safety measures V had in place. I want (but have no right) to know whether the person's experience should have suggested that a precepting and roving role was appropriate.

Anyway, let the real safety discussion begin. As is almost always true, there is more that can be faulted than just one person.

This came to my mind as well. If this nurse was not familiar with vecuronium OR Versed, then a lot of these other checks don't come into play (without looking up the med, of course).

Vec is a powder that needs to be reconstituted. (If you've never given either drug, this wouldn't be a red flag).

Versed should have been looked up under the generic name. (If you don't know it's the brand name, or just have a brain fart and type in "VE", midaz doesn't come up as a choice for you to even notice. Only vec.)

Both drugs should be monitored anyway. (The doctor said to give it and didn't give any other orders for extra monitoring. Doc didn't seem concerned and nurse wasn't familiar with the drug...no red flag.)

Both drugs need a witness - in some places, and in other areas where anesthesia might be (like procedure and imaging areas...), neither might require a witness. In my experience, vec definitely doesn't always require a witness. And again, if you don't know the drug, well....

All this to say that looking up unfamiliar meds is (obviously) important and it doesn't always happen. We all know that. Especially when running all over as a task nurse, with minimal info about the patient, and probably feeling pressured to move quickly.

[K9lover, ASN, RN]

I work in an ICU and over-ride the med cabinet very frequently when emergencies are going on. I know my meds well enough to know that a bottle of Versed looks very different from a bottle of Vecuronium. I honestly find it pretty tough to make excuses for this nurse, as it doesn't even sound like this was an emergency situation where adrenaline is running high and there's pressure to hustle with the med. I am usually the last person to hop on the nurse-blaming band-wagon because I know horrible things happen, mistakes get made, and it's not typically reflective of the nurse's competency. In this case, however, I can't help but wonder what on earth was going through this nurse's head.

I does not sound like an emergency to me either but when you have for tests be they non-emergent MRIs/CTs/PETS crawling up your a** and hounding you in the interest of sticking to their schedule it is stressful. Reason # 43 why I do not do hospital nursing anymore; having tech browbeat and just get generally obnoxious over having that patient at whatever test area on the DOT on their schedule. Last hospital I worked at had a 'hands-off' thing which had nurses timed to the nanosecond having that patient down for their test.

More than a few times I was pushing that 1000 pound stryker bed solo as whatever department DEMANDED I drop everything in the interest of getting that patient to whatever test with only reason being they needed a test prior to DC. I grew to loathe techs although in all fairness they are likely being pressured by someone else to not fall a nanosecond behind schedule.

I never assume anything in the hospital is non-emergent; just because the patient is non emergent does not mean the hospital is not pressuring everyone to get 'er done stat particularly if the test is all they need to DC them so they can shovel them out and get an admit.

Granted not the same as adrenaline running high but that, in itself, could lend itself to a bit of complacency. Last time I was involved in a RAT with an emergent intubation I called out the med I obtained and was giving; glad I did since another nurse who did not call it out was about to give the propofol I was also about to give.

I hate to 2nd guess on why h/she was not looking up versed under midazalom? Brand names have not been used in acute care or anywhere else for quite some time. Perhaps h/she was pressured and thought looking under 'v' would be a shortcut. Not all nurses, myself included, have worked with paralytics but most experienced nurses know what versed looks like but this may have been a new nurse. New grads were not hired on to critical care in years past but that is not the case any longer.

Med errors are not new but sensalitionaling them on social media is and, as others have cited, this yellow journalism in pointing out same drugs are used in lethal injections is included for what reason?

[wondern, ASN]

Well, this source has posted the CMS investigatory report.

Overall nauseating.

Without disregarding the "5 Rights" error, this (nursing/safety community) discussion leaves much to be desired, and frankly IMO V's accusations and statements to CMS betray hospitals' utter refusal to look at themselves. There are major factors (*major*) factors barely mentioned; mentioned only in passing.

Again, without defending the failure to complete 5 Rights, here are a few other (reported) facts I picked up from the report:

*V had instituted "World's Best Performance-Timing-and-Statistic-Producing EMR" within the month prior to this event. ...

*The nurse was performing a roving/"help-all" role. ...

*The patient's actual primary nurse could not leave the department to go medicate her own patient because she was watching yet another nurse's patients - - that nurse was on lunch break.

*There was no med scanning ability in PET scan. Since at least two of the hospital representatives/officers discussed with CMS the "numerous"/"multiple" safety points the nurse supposedly bypassed, I think is fair game to note ...

*Nothing at all mentions the experience level of the erring nurse. I bring this up only because of the lack of familiarity with the fact that vecuronium is powdered, midazolam is not...

Anyway, let the real safety discussion begin. As is almost always true, there is more that can be faulted than just one person.

Thank you for pointing all that out so well, JKL33. I agree. It does seem it was only mentioned in passing. Sounds like a new nurse in a maybe 'new for her', critical care short-staffed area without experience, supervision or technology limits on drugs, trying to help in a very big medical trauma center.

I feel sad for the patient and their family and I also feel very sad for the nurse, that her mistake was that drug instead of something like Lasix, and that she did not have an MD or anesthesia person or experienced critical care nurse close enough by helping her or seeing her mixing it up.

BTW, did it actually say somewhere that she mixed the drug? Does it come premixed as well?

It is so very sad for everyone involved. Experienced nurses and staff are like guiding lights for new people, who are so proud to be where they are, just trying to help without asking others, enough at times, for help. Their experience saves lots of lives by helping the new ones.

I'm looking at the big picture JKL33 so brilliantly pointed out and feeling some empathy for the 'maybe new' nurse. What a horrid way to relearn a basic med administration lesson when you were really trying to help out. She/he worked hard for that license as we all know, so very well, and made a medication mistake in that one or two seconds that dramatically changed others and her life forever, in one little push of a syringe. I imagine her thinking when she left that morning for work and also the patient for surgery that she was going to have a good day, so sad.

Who knows what else may have factored in? Maybe she was in working extra due to short-staffing and overtired as well. Who knows but wouldn't that just be the...well, you know?! Just ironic to think of that possibility. Obviously, we could do that different scenario view all day but it's not a real unlikely one as a nurse and in December, 'slam season'.

I pray for the patient and family and also the nurse. What a sad accident. I also pray all hospitals to respect and retain their experienced nurses when possible, and plenty of them, and that people triple check their drug name, dosage, route, pt. name, frequency, etc.

A lot of us, I included, have made mistakes when we've been in a hurry and got very very lucky it was not a life-threatening drug.

Working short-staffed makes you feel like you're playing catch up all day. We all know this. Even though it's hard in a busy, sometimes wild and crazy, environment sometimes, make that a lot of times, we just have to slow down and think and remember our basic teachings. We are all only human though. We all make mistakes. I hope everyone, both the family and the nurse are starting to heal from all this. It looks like it was last December that the death occurred. God bless all.

I've never heard of the drug and didn't mind the article pointed out what its uses include. It was educational for me. Also, who knows, some nurse could read the article and then see the drug and instead of giving it say, "Oh no, that drug is used for lethal injection. That's not the drug I want." Who knows??? I'm just glad there was an article printed in the first place to shine a light on a problem, and possibly save lives. I would imagine they had some pressure to not print that.

I admit I read the Tennessean's article first but I still don't mind the sensationalism if it saves a life. Maybe someone in Charlotte will read it and/or be saved by it.

[Julius Seizure]

There are so many weird things, like the baggie. Why would there be a baggie with the med? Unless it had both the vial of vec and a vial for reconstituting together in a baggie in the Pyxis.

That would make sense to me - our Pyxis stocked vec in this way. No question about what to reconstitute with (NS vs. sterile water) because it was provided right there for you.

[Anonymous865]

I'm sure the reason the news stories mention that these drugs are used in lethal injection is because there have been a lot of news stories about states being unable to get the drugs they use for lethal injection. As a result the states have come up with a different lethal injection cocktail.

In August Tennessee executed their first inmate in a decade and used a new cocktail that included midazolam, vecuronium, and potassium chloride. There were more news stories about how the prisoner suffered and how barbaric this was. Readers of the Tennessean already would have been familiar with these drugs in relation to the August Execution and lawsuits from other death row inmates.

Tennessee death row must choose: Electric chair or lethal injection?

Opinion | Executions With an Extra Dose of Cruelty - The New York Times

Access Denied

Tennessee death row inmate wants electric chair as '''lesser of two evils'''

Firing squad should be a choice for death row inmates, lawsuit says