Nurse kills patient by giving vecuronium instead of versed

[caligas]

I know of a resident who inadvertantly delivered 100 mcg of intrathecal fentanyl instead of epidurally.
Small mistake could lead to terrible outcomes.

They keep breathing? Probably pretty itchy.

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[Aether2000]

Absolutely when being wheeled to the OR after Versed they are being monitored by the CRNA or anesthesiologist. Incompetence is administration of an intentionally sedating drug placing the patient in a room by themselves in a PET scanner without applying monitors that are readily available in such units, then pulling them out of the scanner wondering why they are dead. Clearly no one communicated or even attempted to communicate with the patient throughout the entire scan.

 

[caligas]

Correct. Surgeon is still working there.

When was that incident?

 

[Pinotnoirmyanmar]

Patient would have likely had good pain relief. There are actually human studies looking at both IT/epidural oxytocin for analgesia

Ha! I actually looked up those studies and at least with intrathecal oxytocin, the dose was only around 100mcg. The oxytocin syringe I had was a whole 20mg ready to squirt into the IV bag after the baby came out

I never understood why people will predraw everything like pitocin, ancef, zofran ect. This can easily lead to errors, none of these drugs are emergency meds, and it takes a lot more work....

I ended this practice of mine, at least in OB, as a result of my near miss. But I thought about how many people feel pre-drawing medications is a waste of time and increasing risk unnecessarily, and I wonder how different is it than having pre-made up syringes such as Ancef, sux, phenylephrine, etc available. Obviously oxytocin isn't an emergency medication, but I do enjoy having a syringe ready to go as soon as I want to give the med. It takes (marginally) more work to draw everything up at the beginning, but I save a little bit of time not having to draw it up later, so it's a wash in my mind. And of course a person's layout is important - do they have all their syringes all in the same pile where it's easy to mix things up when s**t hits the fan? Are things labelled clearly? For example, I am pretty organized and tend to put my less urgent meds in the back on the Pyxis as opposed to right in front of me on the machine. But I am still a pretty fresh new attending and I'm sure my perspective on these matters will evolve as I gain more experience.

I found this article which has a pretty extensive list of all the crap that's been accidentally administered intrathecally, and not surprisingly it looks like more than half the time the patient had suffered pretty significant morbidity. Interestingly, they recommend doing a CSF lavage as a mainstay of therapy, which I have never seen before. I couldn't insert a link since this is a throwaway account, but if you Google the article title below, it's the first result.

"Inadvertent intrathecal injections and best practice management"

 

[btbam]

When was that incident?

10 years ago probably. The surgeon actually asked the anesthetist what she gave cause he felt the Roc tingle as it went in.

 

[dchz]

An oldie but goodie.

I'm reading through this right now. Very interesting perspectives, I am def born into the militaryMD camp, but I'm seeing the other side too...

One of the fallacies in my past operating assumptions is that everyone is intelligent, well-trained, driven, and cares. I am learning that's not the case. Still not sure what the optimal response is though...

 

[Aether2000]

I guess it could have been worse-
Intravenous injection of liquid halothane.

Dwyer R, Coppel DL.

Anesth Analg. 1989 Aug;69(2):250-5. No abstract available.

 

[nimbus]

I know of a resident who inadvertantly delivered 100 mcg of intrathecal fentanyl instead of epidurally.
Small mistake could lead to terrible outcomes.

They keep breathing? Probably pretty itchy.

I used to work with an old timer who routinely gave 1mg of PF MS in the intrathecal space. His patients were very comfortable and had no significant adverse effects aside from some additional drowsiness. I doubt a 5x usual dose of a lipid soluble opioid like fentanyl will be of much consequence. Also 50mcg was routinely used during the original dose finding studies.

 

[deleted126335]

I used to work with an old timer who routinely gave 1mg of PF MS in the intrathecal space. His patients were very comfortable and had no significant adverse effects aside from some additional drowsiness. I doubt a 5x usual dose of a lipid soluble opioid like fentanyl will be of much consequence. Also 50mcg was routinely used during the original dose finding studies.

I would expect more than the usual amount of n/v, itching, and urinary retention.

 

[MoMoGesiologist]

Can we stop offering people benzos and narcotics because they're a little scared or uncomfortable of going through the scanner?

Why does it seem like patients today have expectations for zero discomfort or pain? I'm not withholding meds from you because I'm cruel or a jerk, it's because I don't want to chance of death or disability.

It's ridiculous the number of times anesthesia gets called to tube a patient because they're back hurts or they're scared and the inpatient team thinks a general is the answer. What's even worse is that patients think this is a great idea also!

 

[somedumbDO]

Had an attending during residency did a lot of demerol spinals for short cases. Well the attending (doing own case) asked for demerol and got dilaudid from the pharmacy, they both were in those tube things. She never double checked. and gave 1mg IT dilaudid...... it took a narcan drip to fix that one. I was on call that night and got asked multiple times to check on the patient.

Listen we have all made medication errors. I have, forgot to double dilute ketamine for a peds case (I use very frequently for lap pylos), rapid turnover, last case in a 10 hr day. Gave 10x the dose felt like a dumb@ss, nothing happen other than took a while to wake up. But lesson learned and am SUPER cautious now. The real issue is that they compare us to these airline pilots so much.... Well do pilots work 70 plus hrs a week or stay up for 24 hrs at a time. If the truck driver has to take a break after so many hours why cant we? I think that the travesty of this situation is the production and financial pressures of anesthesia. Or when the public questions why do we make so much money....

 

[nimbus]

Had an attending during residency did a lot of demerol spinals for short cases. Well the attending (doing own case) asked for demerol and got dilaudid from the pharmacy, they both were in those tube things. She never double checked. and gave 1mg IT dilaudid...... it took a narcan drip to fix that one. I was on call that night and got asked multiple times to check on the patient.

Listen we have all made medication errors. I have, forgot to double dilute ketamine for a peds case (I use very frequently for lap pylos), rapid turnover, last case in a 10 hr day. Gave 10x the dose felt like a dumb@ss, nothing happen other than took a while to wake up. But lesson learned and am SUPER cautious now. The real issue is that they compare us to these airline pilots so much.... Well do pilots work 70 plus hrs a week or stay up for 24 hrs at a time. If the truck driver has to take a break after so many hours why cant we? I think that the travesty of this situation is the production and financial pressures of anesthesia. Or when the public questions why do we make so much money....

Pilots can work a lot on a particular day but are required to get adequate rest over several days.


Duty Limitations of an FAA Pilot

 

[Psai]

I know of two cases, both OB related. In one case someone drew up 1 MG of epi ( instead of the spinal marcaine ) and gave it intarthecally, amazingly nothing bad happened. in another case a resident dosed up an epidural for C/S with the ancef (predrawn of course ) instead of 2% lido. Patient seized, aspirated, and spent some time in the ICU....

How do you know that the ancef caused the seizure?

 

[Psai]

Had an attending during residency did a lot of demerol spinals for short cases. Well the attending (doing own case) asked for demerol and got dilaudid from the pharmacy, they both were in those tube things. She never double checked. and gave 1mg IT dilaudid...... it took a narcan drip to fix that one. I was on call that night and got asked multiple times to check on the patient.

Listen we have all made medication errors. I have, forgot to double dilute ketamine for a peds case (I use very frequently for lap pylos), rapid turnover, last case in a 10 hr day. Gave 10x the dose felt like a dumb@ss, nothing happen other than took a while to wake up. But lesson learned and am SUPER cautious now. The real issue is that they compare us to these airline pilots so much.... Well do pilots work 70 plus hrs a week or stay up for 24 hrs at a time. If the truck driver has to take a break after so many hours why cant we? I think that the travesty of this situation is the production and financial pressures of anesthesia. Or when the public questions why do we make so much money....

Should have done some intrathecal narcan

 

[anbuitachi]

Can we stop offering people benzos and narcotics because they're a little scared or uncomfortable of going through the scanner?

Why does it seem like patients today have expectations for zero discomfort or pain? I'm not withholding meds from you because I'm cruel or a jerk, it's because I don't want to chance of death or disability.

It's ridiculous the number of times anesthesia gets called to tube a patient because they're back hurts or they're scared and the inpatient team thinks a general is the answer. What's even worse is that patients think this is a great idea also!

i think the issue is that you have a billion other things to do, do you really want to hold the patients hand while he/she get scanned? do you want to repeat teh same scan 100 times cause patient wont lie still?

 

[abolt18]

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..

Like Dr death the sequel? But his nurse instead?

 

[KetamineKetayours]

there is a copy of the CMS report floating around

 

[Mr.S]

. Or when the public questions why do we make so much money....

Thats the crux of the problem with our visibility.
We make so much money. How do you empathize with someone who is filthy rich?

They dont necessarilly see the good we do.
Why? Because nothing bad happens. and... CRNAS do the exact same thing.
Why dont bad things happen? Because physicians have sacrificed many things to get to where they are. and continue to do so.
But the thing is.. SOMETIMES bad things happen. as evidenced by this thread.
As someone pointed out earlier... no amount of system changes can prevent the level of incompetence exhibited by the nurse who injected vecuronium.

Vanderbilt is ground zero for training nurse practicioners.

 

[abolt18]

Nothing beats the story someone posted on here before. I'm posting it from memory so forgive me if I'm mistaking any details.

Abdominal case happening in academic center, surgeon feels a little under the weather. CRNA offers to start an IV and give him a liter of fluids. Surgeon scrubs out and lets resident continue while he sits next to the CRNA and she starts his IV and hangs a bag of fluids. Resident decides to comment at this time about how the belly feels tight. CRNA pushes a bunch of roc and pretty soon the surgeon comments about how he feels funny. At this point, the CRNA realizes her mistake and rips out the IV as the surgeon collapses on the floor. IIRC they called for anesthesia help and bagged the surgeon while they got an IV in him and he did fine.

Would be great if anybody could find the post. I learned from it never to try ripping the IV out in case of a drug error.

I remember reading that post! Classic.

 

[Mman]

there is a copy of the CMS report floating around

For the win... 1 mg of Vecuronium pulled from the ICU pyxis for a patient in PET scan by someone apparently unaware that Versed does not require reconstitution from a white powder.

 

[dhb]

For the win... 1 mg of Vecuronium pulled from the ICU pyxis for a patient in PET scan by someone apparently unaware that Versed does not require reconstitution from a white powder.

White powder drugs are a hell of a drug.

 

[Orin]

Man, that sucks for everyone involved. Hopefully Vandy and everyone learns from this mistake.

 

[dchz]

Saw this today at the VA.

Now who's the stupid one for putting the sticker on there...

 

[nimbus]

View attachment 243519

Ours are idiot proofed for those who don’t know that vec causes respiratory arrest.

 

[dchz]

well, perhaps it's also a systems problem.

 

[jwk]

I'm reading through this right now. Very interesting perspectives, I am def born into the militaryMD camp, but I'm seeing the other side too...

One of the fallacies in my past operating assumptions is that everyone is intelligent, well-trained, driven, and cares. I am learning that's not the case. Still not sure what the optimal response is though...

I think one has to get over this I'm "intelligent, well-trained, driven and cares" attitude thinking that they can't make a mistake. They can.

 

[Mman]

I think one has to get over this I'm "intelligent, well-trained, driven and cares" attitude thinking that they can't make a mistake. They can.

Humans can and will make mistakes. If you are a human, that includes you.

 

[Cryc_to_the_point]

Making a mistake is a given, making a mistake this epic is not.

 

[deleted162650]

well, perhaps it's also a systems problem.

Yes, they need a better system in place for not hiring *****s.

 

[MoMoGesiologist]

Yes, they need a better system in place for not hiring *****s.

Good thinking, rainbow care bear

 

[deleted162650]

Good thinking, rainbow care bear

Thanks, Asian mouse thing?

 

[MoMoGesiologist]

Touché

 

[nimbus]

Good thinking, rainbow care bear

Thanks, Asian mouse thing?

When nerds collide.

Furry v Manga

 

[fakin' the funk]

Most states have greater than a 10:1 ratio of female to male nurses. The smallest is 4:1. It's not sexist, it's numbers.

A) you're sexist, and intellectually lazy, it's not hard to say "he or she" - you actually don't know the sex of the person in question
B) you don't accept a 10% error rate in most things related to anesthesia, why this? (See A)

 

[fakin' the funk]

You realize that sux is a paralytic that doesn’t sedate a patient? And that the patient had a painful myoclonus as he was losing all motor function while he was wide awake? Does that sound scary or dangerous to you?

A) I don't think you know the difference between fasciculation and myoclonus
B) are either painful?
C) if the patient truly had myoclonus as you say, that's from the etomidate, not the sux, meaning you have disproved your own point
D) stick to tomatoes my friend, yours are delicious

 

[fakin' the funk]

TXA spinal via Attending at my training program for total knee. Pt spent several days in icu having seizures but ended up ok. Drug errors are unimaginable until it happens to you...

Wow.

 

[VA Hopeful Dr]

A) you're sexist, and intellectually lazy, it's not hard to say "he or she" - you actually don't know the sex of the person in question
B) you don't accept a 10% error rate in most things related to anesthesia, why this? (See A)

In Tennessee it's actually 12:1, so a 8% error rate.

I am neither as I have posted nothing on the subject except pure numbers but thanks for that.

I have no idea what the error rate is in anesthesia. If we're talking all errors, 8% wouldn't necessarily be terrible. If it's 8% errors like this, that would be a different story but since we're talking about potentially calling someone by the wrong gender in passing, seems the bar for an error is quite low.

 

[jwk]

Making a mistake is a given, making a mistake this epic is not.

Sadly, epic mistakes are a given as well. They're not common, but the number is far from zero.

 

[San Marzano]

A) I don't think you know the difference between fasciculation and myoclonus
B) are either painful?
C) if the patient truly had myoclonus as you say, that's from the etomidate, not the sux, meaning you have disproved your own point
D) stick to tomatoes my friend, yours are delicious

K u r the winner congrats

 

[BobLoblaw78]

The very lowest ratio of women to men in nursing I could find was in Nebraska... it's 3:1. The vast majority of states have a 10:1 ratio. It's not sexist, it's likely.

How can you presume to know a person's gender without asking them??? What type of hospital....no, what kind of country....no, what kind of world are we living in?????? You MONSTERS!!!!! I bet you guys listen to "Baby, it's cold outside." MONSTERS!!!!

 

[BobLoblaw78]

Two cases come to mind. One where the resident gave protamine (instead of what the surgeon asked for--"dopamine") on pump. Game over.

Second. Provider gave bag of bupivacaine, toradol, morphine intravenously. It was intended for knee injection/periarticular. Patient turned white and they were thinking the IV had infiltrated. The patient responded appropriately to the medications. Had a quick run through of LAST treatment. Thank goodness for lipid emulsion.

 

[btbam]

Wow, would like to hear more about the first case.

 

[nimbus]

Two cases come to mind. One where the resident gave protamine (instead of what the surgeon asked for--"dopamine") on pump. Game over.

My old residency director would call that “an anesthesia clean kill”.

 

[BobLoblaw78]

Wow, would like to hear more about the first case.

Old crotchety VA CT surgeon that intimidated most people. I think the resident was CA-2 at the time, may have been CA-1. We weren't allowed in the heart room as CA-1's and maybe this was reason why. I can't remember for sure. The resident seemed a bit meek and mild type to me (maybe before or maybe only after this incident). He was trying to just be seen and not heard and get through the case without getting skewered. The surgeon liked to call his own shots concerning the vasopressors and didn't like to be questioned about it by resident or attendings (as I'm sure many had tried to over the years). He would get very belligerent if questioned on the pressors or other treatments. So the resident hears him say "protamine" (but we all know the end of the story and what he really said). Didn't want to question him, so guess what he gave? This surgeon would also do some cases off-pump, so maybe the resident just wasn't thinking clearly and thought they were off-pump. Or maybe he had not read enough and he didn't realize the consequences of protamine on-pump. I never thought it would be cool to ask him directly....

 

[btbam]

Old crotchety VA CT surgeon that intimidated most people. I think the resident was CA-2 at the time, may have been CA-1. We weren't allowed in the heart room as CA-1's and maybe this was reason why. I can't remember for sure. The resident seemed a bit meek and mild type to me (maybe before or maybe only after this incident). He was trying to just be seen and not heard and get through the case without getting skewered. The surgeon liked to call his own shots concerning the vasopressors and didn't like to be questioned about it by resident or attendings (as I'm sure many had tried to over the years). He would get very belligerent if questioned on the pressors or other treatments. So the resident hears him say "protamine" (but we all know the end of the story and what he really said). Didn't want to question him, so guess what he gave? This surgeon would also do some cases off-pump, so maybe the resident just wasn't thinking clearly and thought they were off-pump. Or maybe he had not read enough and he didn't realize the consequences of protamine on-pump. I never thought it would be cool to ask him directly....

I’m just trying to imagine the total cluster****/panic that ensued in the minutes after he gave it. Yeesh...

 

[MoMoGesiologist]

It's terrible that he worked with a surgeon that made him too afraid to speak up and a patient got hurt as a consequence. I would say this is another systems error.

 

[anbuitachi]

It's terrible that he worked with a surgeon that made him too afraid to speak up and a patient got hurt as a consequence. I would say this is another systems error.

system error + resident error. you can't just blindly follow someone elses instructions... a CA2 shouldve realized to not give protamine. i wonder if this resulted in a lawsuit

 

[MoMoGesiologist]

system error + resident error. you can't just blindly follow someone elses instructions... a CA2 shouldve realized to not give protamine. i wonder if this resulted in a lawsuit

When you have a surgeon riding your ass, making the OR super tense, feeling time pressure that doesn't need to exist, it's very understandable a resident wouldn't hear things correctly (also scared to ask surgeon to repeat himself), and would fumble things and not perform at their best. I bet if the resident was asked outside the OR what the consequences of giving protamine on pump were, he would know.

Some surgeons are just so nasty to work with. If the attendings arent saying anything, no way a resident will.

I'm not defending the resident, but I can understand why such a big no-no happened. We have all made mistakes in the OR we never thought possible. Just usually it's stuff that really doesn't matter.

 

[vector2]

Old crotchety VA CT surgeon that intimidated most people. I think the resident was CA-2 at the time, may have been CA-1. We weren't allowed in the heart room as CA-1's and maybe this was reason why. I can't remember for sure. The resident seemed a bit meek and mild type to me (maybe before or maybe only after this incident). He was trying to just be seen and not heard and get through the case without getting skewered. The surgeon liked to call his own shots concerning the vasopressors and didn't like to be questioned about it by resident or attendings (as I'm sure many had tried to over the years). He would get very belligerent if questioned on the pressors or other treatments. So the resident hears him say "protamine" (but we all know the end of the story and what he really said). Didn't want to question him, so guess what he gave? This surgeon would also do some cases off-pump, so maybe the resident just wasn't thinking clearly and thought they were off-pump. Or maybe he had not read enough and he didn't realize the consequences of protamine on-pump. I never thought it would be cool to ask him directly....

Ugh, that's just absolutely awful, and it's the reason I don't let junior residents new to pump cases draw up or administer protamine unless I'm in the room. I also stress that any verbal from the surgeon needs to be called back and loop completed because many times the resident has no idea if an order is going to perfusion, anesthesia, or the circulator. Lastly, I tell residents that they should stand up by the drape, learn the steps of the various procedures and sequence of cannulation, plege, and decannulation so they can anticipate what's required, and make their presence known to the surgeon by asking pertinent questions.

This may not always be possible (esp with d'ickhead god complex surgeons who demand absolute silence and only speak to attendings), but I found many who appreciated that I asked about what they thought of the aorta, the suitability of the coronary targets, their thought process for why a particular valve wasn't amenable to repair, etc. A word to the meek residents among us who would prefer to be seen and not heard in the heart room- respect is earned when it becomes apparent you are a part of the team and not a faceless anesthesia monkey who just puts the tube in.

 

[MirrorTodd]

Inter professional equivalency for some of the mistakes we've seen made? (Obviously not talking about the dead pt)
A surgeon mistakes a kidney for a tumor. How can this happen?