Nurse kills patient by giving vecuronium instead of versed

[jameskimp]

At Vanderbilt, a nurse's error killed a patient and threw Medicare into jeopardy

Pretty crazy how this happened. Can’t imagine the torture the patient was going through in their last moments.

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[Iso4ane]

Quoted from the article “The nurse then unknowingly gave the patient the vecuronium, telling the person it was “something to help him/her relax,” according to the investigation report,”.

Not exactly a lie, in a morbid sort of way.

 

[urge]

At Vanderbilt, a nurse's error killed a patient and threw Medicare into jeopardy

Pretty crazy how this happened. Can’t imagine the torture the patient was going through in their last moments.

This would not have happened if brand names were also programmed in the Pyxis machine. Goes to show how the purists with their elitist attitude result in patient deaths. Most likely this nurse will be fired and the elitist pricks on the pharmacy committee will still not program brand names into the system, because I’m sure we have all heard the idiots say only generic names are allowed.

 

[deleted162650]

All the vec I’ve used came as powder requiring reconstitution. Is it also available in ready to go liquid form?

 

[Mr.S]

This would not have happened if brand names were also programmed in the Pyxis machine. Goes to show how the purists with their elitist attitude result in patient deaths. Most likely this nurse will be fired and the elitist pricks on the pharmacy committee will still not program brand names into the system, because I’m sure we have all heard the idiots say only generic names are allowed.

That is exactly what contributed to it..

Perhaps, brand names should be banned. Just call the medicine by ONE name only.

The nurse should have looked at the vial really.
vecuronium should not even be stocked down there anyway.
They look entirely different.
Vec has to be reconstituted. Versed does not
Vec vial is waaaayy larger..

 

[McPoyle]

All the vec I’ve used came as powder requiring reconstitution. Is it also available in ready to go liquid form?

I agree, I’ve not seen liquid vec. My other question is how much versed was she trying to give?? I mean a cc of either (depending on the concentration) seems dubious to me. I just feel like there is more to what happened.


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[Mr.S]

I just feel like there is more to what happened.


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Like what more? SHe gave vec instead of versed.. a ml of vecuronium can cause resp arrest and she likely gave 2ml. which is the standard dose of versed...
The question is.. was someone watching the resp pattern at all times?Should there have been a capnogram? was the spo2 monitor on?

As soon as the spo2 start dropping.. youll spring to action, pull the mofo out of the tube and save his life..

 

[Mman]

Like what more? SHe gave vec instead of versed.. a ml of vecuronium can cause resp arrest and she likely gave 2ml. which is the standard dose of versed...
The question is.. was someone watching the resp pattern at all times?Should there have been a capnogram? was the spo2 monitor on?

As soon as the spo2 start dropping.. youll spring to action, pull the mofo out of the tube and save his life..

This was a nurse giving a dose of versed (oops) for what was probably a CT or maybe an MRI. Even if there was probably a pulse ox hooked up to the patient but that's about it. Once they noticed the sat start dropping they could go into the scanner to ask the patient to take a deep breath. Try that a few times. Maybe shake them awake and yell at them a bit and turn the O2 flow up from 2L to maybe 6L. I mean by then the sat is probably dropping like a rock. And who in that scanner is going to spring to action to intubate this patient? The radiology tech? I'd be 100% sure there wouldn't even be a laryngoscope in the room. I mean maybe there is an ambu bag somewhere within 100 or 200 feet but that's about all you'd likely find. And then someone would have to realize they needed it and go get it and hook it up to O2 and know how to use it, etc.

That mistake of giving a dose of Vecuronium was likely irreversibly lethal the moment it happened in that setting. I mean the patient didn't die instantly, but there would not have been the properly trained individuals and equipment close enough to intervene. Nobody was showing up to help until they called a code and by then in an old stroke patient it'd be too late. Nevermind the fact that when it mentions nobody noticed for 30 minutes that the patient clearly wasn't hooked up to any monitor. The staff was probably just pleased at how still they were holding.

The system mistake was having that nurse be able to access vecuronium in the first place. I mean that's not even a code drug. Nobody that doesn't know what it is should ever have access to it. And yes it's somewhat insane that somebody could confuse a vial of white powder with a vial of versed. I mean that sounds like a nurse that had never even given versed before.

 

[FiremedicMike]

Like what more? SHe gave vec instead of versed.. a ml of vecuronium can cause resp arrest and she likely gave 2ml. which is the standard dose of versed...
The question is.. was someone watching the resp pattern at all times?Should there have been a capnogram? was the spo2 monitor on?

As soon as the spo2 start dropping.. youll spring to action, pull the mofo out of the tube and save his life..

Have you ever reconstituted versed?

Have you ever seen vec that didn’t need reconstituted?

It’s hard to imagine mistaking versed for vec and vice versa for that reason alone.. that’s why folks think there might be more to the story..

 

[nimbus]

That is exactly what contributed to it..

Perhaps, brand names should be banned. Just call the medicine by ONE name only.

The nurse should have looked at the vial really.
vecuronium should not even be stocked down there anyway.
They look entirely different.
Vec has to be reconstituted. Versed does not
Vec vial is waaaayy larger..

The person who made the error was undoubtedly unfamiliar with both drugs. It’s not the first time that exact error was made. I know of one other case 25 years ago where the error was made by a physician.

 

[Cryc_to_the_point]

Both of these are true:
1. The nurse messed up. She injected a medication which she obviously did not check and or did not know what it was. I just looked around, I cannot find vecuronium in anything but powder (That's all I've ever seen in person as well).
2. The system is far from optimized there. This should take a monumental amount of failures, not one person being inexperienced/bad day/stupid. I hope that changes.

 

[Mr.S]

Both of these are true:
1. The nurse messed up. She injected a medication which she obviously did not check and or did not know what it was. I just looked around, I cannot find vecuronium in anything but powder (That's all I've ever seen in person as well).
2. The system is far from optimized there. This should take a monumental amount of failures, not one person being inexperienced/bad day/stupid. I hope that changes.

its hard to blame the system when at least a little part of the system relies on someone who knows how to read
The only similarities between versed and vecuronium is that the first two letters of those two words are the same.
At some point people have to be held accountable and not the system.. If we hold the system accountable every single time then our rule book will be one million pages before long.

 

[caligas]

Horrible way to die. assuming 2 mg, probably took quite a while too.

 

[Mman]

its hard to blame the system when at least a little part of the system relies on someone who knows how to read
The only similarities between versed and vecuronium is that the first two letters of those two words are the same.
At some point people have to be held accountable and not the system.. If we hold the system accountable every single time then our rule book will be one million pages before long.

No one denies that the person made a mistake. But you try to design the system so that it's hard for the person to make that mistake. That's like the 99% of the safety improvements in NASA, aviation, and medicine. If you rely on humans to never screw up, well you will be dealing with a lot of screwups. With an error like this, their system had to have several critical failures that made it possible for this to happen.

When failures happen, blaming the individual and not trying to fix the system is simply wrong. You can hold them personally accountable while still trying your damnedest to make it impossible to have it happen again.

 

[deleted162650]

What boggles my mind is that this nurse, obviously unfamiliar with both drugs, would sit there and read the (fine print) instructions for reconstitution, but not see the “VECURONIUM” on the front. To me this goes beyond simple malpractice and borders on criminal negligence.

 

[T-burglar]

Don’t the bottles also say “paralyzing agent” on them? I have to say though I dont think those words stand out very well . I think the bottle should have “LETHAL PARALYZING AGENT” on it in massive lettering with a skull and crossbones. And only in very small letters somewhere does it read which drug it is.

 

[deleted697535]

This would not have happened if brand names were also programmed in the Pyxis machine. Goes to show how the purists with their elitist attitude result in patient deaths. Most likely this nurse will be fired and the elitist pricks on the pharmacy committee will still not program brand names into the system,

Don't some drugs have 5 or more aliases tho? How would that work?

I'm sorry but this person should be fired. For many reasons.

No monitoring after either midaz or vec!?! Good night...

 

[deleted50478]

No one denies that the person made a mistake. But you try to design the system so that it's hard for the person to make that mistake. That's like the 99% of the safety improvements in NASA, aviation, and medicine. If you rely on humans to never screw up, well you will be dealing with a lot of screwups. With an error like this, their system had to have several critical failures that made it possible for this to happen.

When failures happen, blaming the individual and not trying to fix the system is simply wrong. You can hold them personally accountable while still trying your damnedest to make it impossible to have it happen again.

I think the system already says to put a pulse ox on. They might have been incapable of ventilating him adequately with an ambu, but they could have called a code and tried while they waited for someone better to show up. Vec killed the guy but it should have just tortured him for a while until it wore off or someone realized what had happened.

 

[deleted126335]

They definitely need a few more lectures about the holes in the Swiss cheese lining up. That will fix it.


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[deleted875186]

Terrible mistake. I agree that vec should not have been available in that pixis. It is not an emergency drug. Multiple interventions may have helped prevent this. Not stocking vec in the nursing pixis. Having a confirmation message on the pixis when you take out a vec or roc vial. Having routine monitoring for sedation. Proper training for nurse administered sedation. Someone that reads the vial before pushing a medicine. Very unfortunate.

I personally think the paralyzing agent label is pretty clear, and it’s written under the vial cap so you have to look at it while drawing up. Clearly it was just overlooked.

 

[anbuitachi]

Terrible mistake. I agree that vec should not have been available in that pixis. It is not an emergency drug. Multiple interventions may have helped prevent this. Not stocking vec in the nursing pixis. Having a confirmation message on the pixis when you take out a vec or roc vial. Having routine monitoring for sedation. Proper training for nurse administered sedation. Someone that reads the vial before pushing a medicine. Very unfortunate.

I personally think the paralyzing agent label is pretty clear, and it’s written under the vial cap so you have to look at it while drawing up. Clearly it was just overlooked.

The ICU keeps their meds somewhere, either cabinet or pyxis. Since its a paralytic, it should be in the pyxis. Doesn't have to be emergency drug

I wonder what will happen to this nurse. if a doctor did this... he/she probably would be sued to hell

 

[Mman]

The ICU keeps their meds somewhere, either cabinet or pyxis. Since its a paralytic, it should be in the pyxis. Doesn't have to be emergency drug

I wonder what will happen to this nurse. if a doctor did this... he/she probably would be sued to hell

I'm assuming this drug was in a radiology pyxis since that is where it was administered and I can't for the life of my figure out why they would need it there.

 

[deleted162650]

I'm assuming this drug was in a radiology pyxis since that is where it was administered and I can't for the life of my figure out why they would need it there.

Because some patients just won’t hold still in the scanner damn it!

 

[T-burglar]

I also think it’s bad that all our paralyzing agents are also called “ muscle relaxant” like it’s xanax or something

 

[dhb]

I also think it’s bad that all our paralyzing agents are also called “ muscle relaxant” like it’s xanax or something

I call them frog juice.

 

[Mman]

I also think it’s bad that all our paralyzing agents are also called “ muscle relaxant” like it’s xanax or something

like someone else in this thread mentioned, I am familiar with a case of a physician ordering a dose of an NMB for a patient that was not intubated and it being given to the patient

 

[Monty Python]

One possibility: the pharmacy tech put vec in the slot marked for versed when restocking. No, this does not excuse the RN from failing to read the label, but perhaps the initial error was pharmacy's. As we've been discussing in another recent thread ... What could go wrong?

 

[Psai]

One possibility: the pharmacy tech put vec in the slot marked for versed when restocking. No, this does not excuse the RN from failing to read the label, but perhaps the initial error was pharmacy's. As we've been discussing in another recent thread ... What could go wrong?

The article says the nurse put in "ve" and just took out the first med that came up.

 

[MirrorTodd]

As others have pointed out, I have never seen a vial of vec that isn't in powder form. That nurse straight up killed that patient. No way around it. She completely disregarded multiple safety features both built into the system as well as all the classroom teaching.

 

[pgg]

At a hospital I used to work at, an OB gave a verbal order for 50 mcg of fentanyl for a laboring patient.

OB nurse entered the order as sufentanil in the computer.

Went to the Pyxis to check out the sufentanil, but couldn't find it. Checked out fentanyl instead, because she thought it was the same thing. Used the override function to get it.

Gave 50 mcg of fentanyl to the patient.

Charted 50 mcg of sufentanil.

A little later I was called for an epidural and saw the sufentanil charted ...


Anyway, there's something to be said for not stocking certain high risk medications in areas where they're not needed. I wonder if Vanderbilt still stocks vecuronium in the CT scanner Pyxis.

 

[Aether2000]

In an ideal world, the nurse would be fired, have her nursing license stripped away, and be prosecuted for reckless homicide. What will probably happen is that she will be given a "stern talking to", nothing further will happen to her, then as penance she will mount a campaign to create talking dangerous drug vials that warn you of all the major effects of any dangerous drugs vials you pick up. She will be widely heralded as a pioneer and a hero from that point on, and will win the Nobel Prize in Nursing (yes, I know, but it will be created for her....)

 

[Mr.S]

[

In an ideal world, the nurse would be fired, have her nursing license stripped away, and be prosecuted for reckless homicide. .)

I dont believe that is what should happen! even the fired part. You cant have people scared ****less about their jobs, then worse things happen!! But I do believe these are the important things to address not when I tell the nurse to go get me the glidescope or antibiotics and I say it in a not so nice way because she is giving me the business> She reports me and several weeks of meetings are held to see if i was unprofessional

 

[MirrorTodd]

[

I dont believe that is what should happen! even the fired part. You cant have people scared ****less about their jobs, then worse things happen!! But I do believe these are the important things to address not when I tell the nurse to go get me the glidescope or antibiotics and I say it in a not so nice way because she is giving me the business> She reports me and several weeks of meetings are held to see if i was unprofessional

Worse than a nurse quite literally KILLING a patient? People SHOULD be worried about losing their job for killing someone....they should be so worried about that they actually read the label on the medication they give.

 

[Mr.S]

Worse than a nurse quite literally KILLING a patient? People SHOULD be worried about losing their job for killing someone....they should be so worried about that they actually read the label on the medication they give.

agreed..
I worry about it every second of the day..

 

[Ezekiel2517]

What boggles my mind is that this nurse, obviously unfamiliar with both drugs, would sit there and read the (fine print) instructions for reconstitution, but not see the “VECURONIUM” on the front. To me this goes beyond simple malpractice and borders on criminal negligence.

I have seen vecuronium come pre-reconstituted in syringes and available for immediate administration.

I have heard of this mix-up being made previously. An anesthesiologist labelled their meds wrong and gave roc instead of versed in the holding area. Immediately noticed the patient struggling to breathe and masked and then intubated the patient. Gave actual versed to decrease risk of recall. No major complications afterward, not even litigation or recall.

 

[anbuitachi]

like someone else in this thread mentioned, I am familiar with a case of a physician ordering a dose of an NMB for a patient that was not intubated and it being given to the patient

was this on purpose?

 

[jwk]

The nurse is ultimately responsible since she administered the drug, but there is plenty of blame to go around.

Vecuronium and Versed - one is generic, one is brand name. I don't know about your machines, but both the Pyxis and Accudose setups we have had keep generic and brand name under separate headings - so it wouldn't be possible to select VE for Versed and come up with vecuronium on the same screen, or vice versa.

I'm surprised a hospital like Vandy doesn't have a better setup. Just about every nurse giving drugs in the hospital, with the exception of those in the anesthesia department, has to scan the drug along with the patient ID into the hospital EMR. Certainly not a new system by any means.

NMBs should have extremely limited availability in the hospital - generally OR, ICU, and ER, and perhaps code carts (debatable). Ours are re-packaged by our pharmacy with bright orange labels added that say "Paralyzing Agent".

And like it or not, bad mistakes are made by good people. Should the nurse be fired? I don't know - the newspaper is a horrible place to get your "facts". Why do we still have OR fires? Why do we still have wrong side/site/pt surgery? Why do movie star babies get heparin overdoses that kill them with a brain bleed? All those "never events" still happen, and by and large involve reasonably intelligent and competent doctors, nurses, and other providers. To assume otherwise is foolish.

 

[Aether2000]

When a nurse obtains a medication from the Pyxis, doesn't bother to check the name of the drug displayed on the Pyxis, takes out the wrong drug (I guarantee it was not reconstituted in a syringe), doesn't bother to read the label on the drug or is too stupid to know the difference, reconstitutes a presumed drug that has never in the history of hospitaldom been reconstituted, proceeds to inject a lethal dosage, and doesn't bother to monitor SpO2 in a patient resulting in a terrifying suffocation to death of an anxious patient, the nurse should be fired and her license removed, period.
Rule 1: Always know what you are injecting into a patient
Rule 2: Always know the major effects of the drugs you are injecting
Rule 3: Always monitor your patients after injecting medications that can depress the respirations

 

[urge]

Don't some drugs have 5 or more aliases tho? How would that work?

I'm sorry but this person should be fired. For many reasons.

No monitoring after either midaz or vec!?! Good night...

The nurse was looking for versed in the Pyxis but the stupid thing was programmed for midazolam only. The she went for the closest to versed.

Don't know any drugs with 5 names but if there is one they all should be programmed into the pyxis.

And who the heck thinks monitoring after 2 mg of versed is mandatory? Every other patient I take care of is on xanax po at home. Do they need to be monitored at home?

 

[urge]

I take it nobody here has had a drug error.

Right!!!

 

[anbuitachi]

I take it nobody here has had a drug error.

Right!!!

i agree. depends on what really happened to cause this error but i dont think the nurse should be fired. we've all made drug errors of some sort. i feel like every couple years i hear of a case in PACu where paralytic was given instead of fentanyl/versed or some sort. Obviously PACU is monitored so they were quickly intervened upon. to us who are familiar with these drugs, it feels like a really dumb mistake but im guessing the nurse is not familiar with these drugs.
my worst drug error was when i gave cefazolin when the patient has hx of anaphylaxis to penicillin

 

[DocVapor]

I take it nobody here has had a drug error.

Right!!!

There's drug errors, and then there's drug errors. I bet very few of us here have had the latter, like occurred in the OP.

 

[deleted126335]

There's drug errors, and then there's drug errors. I bet very few of us here have had the latter, like occurred in the OP.

Actually I suspect that many of us have. The difference is that when we have this issue, the problem is virtually always promptly recognized and appropriately treated. Resuscitation is what we do every day. We just don't have the consequences of this type of drug error.

 

[DocVapor]

Actually I suspect that many of us have. The difference is that when we have this issue, the problem is virtually always promptly recognized and appropriately treated. Resuscitation is what we do every day. We just don't have the consequences of this type of drug error.

That's probably a fair statement.

 

[urge]

There's drug errors, and then there's drug errors. I bet very few of us here have had the latter, like occurred in the OP.

I bet many here have had worse.

But it is easier to cover your tracks in the OR.

 

[deleted50478]

like someone else in this thread mentioned, I am familiar with a case of a physician ordering a dose of an NMB for a patient that was not intubated and it being given to the patient

I’ve had something like that that happen. Called to ICU for intubation. Nurses ask what we want while we’re getting set up. I said Sux and Propofol and I’m checking my blade and tube or whatever and nurse pushes something. I said, “What was that?” She says, “sux.” I’m like holy sh give me that propofol, push it asap and tube. This was years ago- Everything turned out okay but I’ll never forget it. If I hadn’t been watching who knows what would have happened.

 

[San Marzano]

I call them frog juice.

 

[San Marzano]

I’ve had something like that that happen. Called to ICU for intubation. Nurses ask what we want while we’re getting set up. I said Sux and Propofol and I’m checking my blade and tube or whatever and nurse pushes something. I said, “What was that?” She says, “sux.” I’m like holy sh give me that propofol, push it asap and tube. This was years ago- Everything turned out okay but I’ll never forget it. If I hadn’t been watching who knows what would have happened.

We were called to the ED as a resident to be "on standby" for a "potentially difficult intubation." The second my attending and I step into the room the ED fellow or attending or whatever it was pushes 200mg of sux and before giving 20mg of etomidate. It was the most bizarre scene I had ever seen, the patient looked like he was having a full body seizure on the bed before he went unconscious. My attending shouted some deservedly choice words at the ED staff before we went back into our safe space in the operating room. Hospitals are dark dangerous places outside of the OR.

 

[Mr.S]

Hospitals are dark dangerous places outside of the OR.

I would venture to say in the OR as well with equal fervor.

 

[fakin' the funk]

1) wow
2) it's hard to engineer systems to prevent harm from this level of incompetence
3 yally are saying "she" to refer to the nurse which is sexist - if the person's gender is known I will retract this