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Discussion in 'Emergency Medicine' started by Dr Mantis Toboggan, Nov 30, 2018.
Vanderbilt University Medical Center could lose Medicare funding
I know we often laugh at the press for making obvious mistakes reporting medicine.
However, this "journal" is called "Modern Healthcare" and yet this quote is from the middle of the very short article"
"...but a nurse accidentally delivered vecuronium, an anesthetic."
Does even a healthcare publication not have it's articles reviewed for a bit of accuracy!
Yeah sadly it was not an anesthetic. Would’ve made the death at least more pleasant.
They both “relax” you. Same error was made many years ago at my training institution by the medicine team doing an LP with the same outcome for the patient.
From a different source
"We don’t know,” an unidentified Vanderbilt official told investigators, according to the report. “(The patient) got such a small dose, and he/she was anxious about the test, so we can’t say it contributed to his/her demise.”
Not a good look for Vandy.
Stfu. A doctor made that mistake? I would think more likely the wrong Med was taken from the Pyxis Edit--which us exactly what happened in this case, so I guess same thing.
Partial solution--only use generic drug names?
No it was a nurse.
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I believe he was referring to nimbus's story
An in neither case were those involved apparently able to recognize the resultant apnea and treat it. Even in such a medication error, prompt recognition, intubation and supportive care, until the medication wears off, would not only saved the patient, but without permanent harm. Unfortunate.
What a horrible way to die
If CMS pulls their funding, does that include GME funding for their residency programs?
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Vandy is not going to loose Medicare funding for these mistakes (vec instead of versed; cover-up)...unless there are absolutely no safety mechanisms and they refuse to put them in place.
I wouldn't worry for second if I was a trainee about my program falling apart.
Correct. They will just need to put giant “PARALYZING AGENT” labels on all vials of NMB’s and all will be forgiven.
It was a medicine resident who didn’t understand that “muscle relaxants” cause paralysis. It was mechanism of action confusion, not name confusion.
Highly unlikely. CMS frequently gives notice of removing funding (sometimes a fast track 7-day notice) that they almost always reverse after an action is corrected or measures are put in place to prevent them from occurring again.
Very true. If every institution that received a letter was barred from participation, I doubt there would be a hospital left that took Medicare.
Looks like there may be more to the story. The Tennessean: Vanderbilt didn’t tell medical examiner about deadly medication error, feds say.
Vanderbilt didn’t tell medical examiner about deadly medication error, feds say
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It almost sounds to me that the relevant attending physician was not told about the medication mistake. Either the physician was made to believe that the patient was given versed and somehow stopped after that, or the physician was putting himself in serious jeopardy to cover for a nurse in a completely different department...I am going with the former.
Or clueless resident filled out the death certificate and called the ME. Could be malfeasance, could be incompetence.
Vandy’s just too big to fail.
“In this case, the drug appears to have caused the patient, who was otherwise stable, to lose consciousness, suffer cardiac arrest and ultimately be left brain dead. The patient died one day later after being taken off of a breathing machine.”
That news article incorrectly calls vecuronium an “anesthetic” and states that vecuronium causes unconsciousness, almost repeating the error of the nurse. If only that was true. The nurse gave an anxious, claustrophobic patient a paralyzing agent and no sedatives. I feel bad for that patient. Hopefully they became unconscious quickly from hypoxia and hypercarbia.
I don't see much egregious in that from a lay person.
Vecuronium is used almost exclusively in conjunction with anesthesia, so lumping it in as an "anesthetic" is not that significant of a mistake from a reporter, and I can guarantee you that if vecuronium is injected in a patient, they will shortly be unconscious... in one way or another.
That's what I was thinking. Can't imagine much worse than being completely awake and lucid but paralyzed while you slowly suffocate to death because you can't take a breath. All the while everyone around you just goes about their business for the first 1 or 2 minutes before you lose consciousness.
I find it appalling that their spokesperson keeps saying that only a small dose was given of the vecuronium. Whether it's 10 mg or 1 mg, vecuronium is a paralytic, and many patients will have enough paralysis with a small dose that it can cause death.
Hopefully Vandy publishes what they do to prevent this in the future. We all should learn from this. This could have happened at any hospital in the nation. When I was a resident, we had a pregnant patient get succinylcholine instead of morphine because a paramedic drew both up and got the syringes mixed up. Luckily it was caught early. (There was another patient next room who was getting RSI'd; he accidentally pushed the leftover succinylcholine instead of the morphine).
We have a policy in my ER where even if the nurse draws it up and gives it immediately, all syringes must be labeled with etomidate, succinylcholine, rocuronium, etc. We have preprinted stickers in our RSI box.
This is where I would bet my money
How it's not a policy to label syringes is beyond me. Not only should this be a policy, it's just common sense.
I wonder if 1 mg would be significant enough to cause respiratory depression. I think it wouldn't affect the patient much aside from mild weakness although 10 mg is a different story.
Maybe not an average person, but a little old lady that might weigh 50-60 kg, it very well could be a paralyzing dose or cause enough difficulty with respirations to cause arrest. Total paralysis isn't required. If you paralyze enough and cause respiratory insufficiency, that can eventually cause respiratory arrest.
There was a nurse who injected her husband with rocuronium and then set the house on fire around him. That would be worse, but I agree it is hard to get much worse than the case in this thread.
Michael guilty of murder, arson
How the hell does a nursing working in such an area not know the difference between versed and vecuronium? Speechless.
Why did I leave the remote control in the refrigerator once? Not paying attention.
I am certain she knew the difference between the two, but was likely working on autopilot.
Yep, the surest way to repeat someone else's mistake is to assume that we're incapable of doing so.
Maybe it's from working in so much critical care and peds. Everyone makes mistakes. I sure have; but I have never confused one so significantly different agent from another and then given 5 times the dosage.
Speaking of autopilot...I was watching the Weather Channel. They had a show about what caused a number of commercial airplanes to crash. Interestingly enough, autopilot mode was a factor in a number of them. Computers and technology can't totally top the living, functioning brain.
P.S. Healthy fear has served me well over the years.
Thank Christ I'm not the only one who has done this.
In a similar vein, I put the hose in the hot tub to fill it up and then went grocery shopping/to the bank/post office.
8 hours later...
My cat is meowing at the sliding glass door that goes out to the lanai, wondering why it looks like a fishtank.
Water bill = 250 or so dollars. Thank you, please drive thru.
And since the patient was being "sedated," during which hypoxia and apnea are always a known risk, was the patient monitored, and if not, why not? If so, why was the hypoxia and apnea not promptly dealt with? Was the team performing the sedation not equipped to handle the side effects of a patient apneic from sedation, whether from a paralytic, benzodiazepine or an opiate?
My guess is that they were probably treating it as anxiolysis, rather than sedation.
That said, if you push 10mg of IV versed, don't lie to yourself - you're aiming for sedation.
Exactly. You shouldn't be pushing anything like versed, regardless of what you're calling it, without being confident you can breathe for the patient if necessary.
Yea and if I even draw up push dose pressors in a syringe and I keep the syringe on me at all times, I still label it. I get some tape and label what it is with the concentration. A must do.
"I can't seem to get this CT angiogram bolus timed correctly..."
We usually just tape the vial of whatever we’re pulling up to the syringe.
I found the CMS report. It nails down all the details. If you don't want a recital of "nursing standard of care", go to page 7.
There are some details that were reported/assumed that were incorrect. It is also a classic case of how these things can go badly wrong as everyone was "busy" and everyone assumed that someone else was taking care of the necessary tasks. (See page 23.)
See page 52 for physician/NP notes.
Makes sense--pretty much what I figured happened. I doubt firing that nurse made anyone safer
Agreed. I wonder how many times that same RN has had to use an override function to give good timely care? Probably a lot.
I have to click through so many safety warnings* in any given shift that it takes a Guru's level of self-awareness to not completely ignore such things.
Firing a nurse and adding mindless safety alerts will not make patients safer. Adding staffing and worrying less about "an excellent experience, every time (TM)" would do a lot more.
*Examples include warnings when I order maintenance fluids on someone who has received a bolus, chose ceftriaxone for someone with a reported mild penicillin allergy, give a heparin loading dose to someone I'm also starting on a heparin drip...
Sometimes, in my crazier moments, I have considered buying a couple hundred copies of "The Boy Who Cries Wolf" and giving them to our pharmacy and nursing administration, as well as officials at the JCAHO, CMS, etc., etc.
The one thing stopping me is that I know they would not make the connection.
Or any degree of allergy for that matter since there is no associated cross reactivity between pcn and 3rd gen cephalosporins.
The nurse has now been charged with reckless homicide.
Vanderbilt ex-nurse indicted on reckless homicide charge after deadly medication swap
Why do we need sedation in the scanner in the first place? Our country is full of namby pambys.
If you read the CMS report, it's pretty clear on why.