Our Safety Pharmacist went over this case with the inpatient team yesterday. I have to admit that I now believe there are two victims. Here is a summary of what we covered:
•75 yo woman w/ intracranial hematoma admitted to Neuro ICU
•Two days later she was alert /oriented & in the Stepdown unit waiting on bed on regular floor
•Sent to Radiology department for total body PET scan where she told staff she was claustrophobic – physician ordered Versed 2 mg IV for sedation – radiology staff requested a nurse from Neuro administer the Versed because their nurses would not be able to perform monitoring of the patient
•Nurse in Neuro ICU (‘help all’ nurse) was going to ER to do a swallowing study and was asked to give this before she went to the ER
•Nurse looked in profile on Neuro ICU ADC for Versed and could not find it. She then used the override function to search for it. She talking to an orientee about the swallow study while entering the first two letters “VE” and selected the first med on the list. She did not notice that she selected vecuronium instead of Versed. She did look at how to reconstitute it and got a pt sticker, flushes, swabs and needle and put it all in a baggie with “PET scan, Versed 1-2 mg” on it and went to Radiology.
•In radiology, she found the patient, reconstituted the med and gave it, then left the PET scan area. She did not remember the exact dose but thought she gave 1 ml. The leftover med was placed in a baggie and given to another nurse. The nurse did not monitor the patient after administration.
•Order for Versed was entered at 1447 and verified by a pharmacist at 1449, but never dispensed from the ADC. Vecuronium was dispensed at 1459 via override.
•The nurse did not document the administration of the med because she was told the new system would capture in the MAR
•The patient was placed in an injection room where she first got a radioactive tracer, followed by what was thought to be Versed.
•After the nurse gave the injection, patient was moved to a patient room where they were expected to wait for up to an hour for the tracer to circulate. Techs could monitor via camera that room & noted her eyes were closed but resolution is not good enough to detect breathing.
•About 30 minutes after injection, patient was found unresponsive. CPR was started, patient was intubated and heartbeat was restored. The patient was brought back to the Neuro ICU (without ever getting the scan).
•At that time, a second nurse asked the first nurse if the med in the baggie was what had been given the patient and when she answered yes, it was then found that it wasn’t Versed, but vecuronium.
•The patient was placed on comfort care and died the following day after being removed from life support
•VUMC did report the death to the medical examiner within 40 minutes…but before there was a ‘definitive conclusion’ about the cause of death
•Provider stated death was due to bleeding, and not medical error
•When the full facts came out, VUMC was threatened with losing CMS status
•Nurse was terminated about a week after the incident
•Nurse was subsequently charged with reckless homicide & impaired adult abuse
Among the Hospital/Medication system issues:
•Bedside barcode verification had not been implemented in Radiology (it was ‘pending’) – it was next on the list. This may have contributed to confusion on med documentation.
•Overrides should not be used in non-emergent situations, such as this
•Independent double check
•Messaging on ADC during removal – there was a red box warning that vecuronium was only for stat orders but no warning that pt should be intubated or about to be intubated
•NMBs should only be kept in areas where truly needed (OR, ICU, ER) and not stored as floorstock or in ADC on other units
•NMBs should be kept segregated from other meds in lidded containers or RSI kits or in ADCs in separate lidded pockets
•Inadequate monitoring of patient after administration of what they thought was a sedative. Even discounting the administration of vecuronium, there should have been monitoring for a patient given Versed – at least pulseox and EKG.
•Inadequate assessment of patient prior to the scan – prior to scan, the patient’s claustrophobia should have been identified when an oral agent could have been administered.
•Search issues with ADC – this ADC defaulted to generic names and the nurse would have to switch to brand name search to find Versed.
•Inadequate transport plan – it could have been noted who would accompany patient and monitor after the administration of the sedative
•Inadequate communication between staff – the PET scan staff recognized the need for monitoring the patient after sedation which is why they asked for someone to come down from Neuro ICU to give the med. But it’s not clear if this was ever conveyed to the nurse that went down with the med.
•Warning labels on the med – the vial DID have a red top with “Warning: Paralyzing Agent” message but it still did not attract the nurse’s attention.
•Multitasking – nurse was CLEARLY multitasking. When she was asked to do this, she was already on her way down to ER to do another test and she was explaining the test to an “orientee” while removing the med. She had to ask for directions to get to the PET scan and then left to go to the ER and do the other study.
•Not the patient’s primary nurse – this nurse was a ‘help-all’ nurse and so may have had little interaction or information on the patient before going to Radiology
•Time pressures – PET unit had a full schedule that day and it had been noted that if the Neuro staff could not come down to give the med, the patient would have to be sent back and the scan rescheduled. This may have contributed to a sense of urgency.
After reviewing the facts, I can see how this could have happened to any nurse. I'm not absolving her of any blame, but it was an honest mistake. It was not her intent to kill the patient. Furthermore, the one person likely to never again make this error was fired. VUMC lost an opportunity to have a person intimately involved to tell the story and describe its effects to staff. I don't see how criminal charges are justified nor do I see how safety will be improved by criminal action.
