Versed and vecuronium. Not the same thing.

Discussion in 'Emergency Medicine' started by Dr Mantis Toboggan, Nov 30, 2018.

  1. turkeyjerky

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    Really? I'm not sure whose interest, public or private, is served by putting this woman in prison. Was she under the influence? If so I missed that part of the report, otherwise I would think she should lose her license and live the rest of her life with the guilt that she killed someone by accident.

    I hate how new reports cite that this is part of the lethal injection cocktail--just pure assholery.

    One (partial) safety measure to prevent medication errors like this--use generic names
     
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  2. Dr.McNinja

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    There are plenty of similar sounding generic drugs.
    She committed gross negligence. Someone died as a result. It's no different than drinking and driving.
     
  3. littlejuan

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    There is a systems failure here as well and she is in part being scapegoated.
     
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  4. Dr.McNinja

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    The system has failures.
    No other nurses killed anyone though.
     
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  5. Atlas Shrugged

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    Absurd. This RN committed gross negligence on multiple levels.
     
  6. sum dude

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    Was Vec in a special RSI pixis? Was there a special override for RSI meds? Was the Vec labeled in a different color-coded bottle than Versed? Lots of system fixes to make sure this doesn't happen. Was the RN intoxicated or on meds when he/she screwed it up? Did the nurse knowingly give "small dose" of Vec to quiet patient? If not, to prosecute this is absurd.

    I agree RN/hospital should have civil penalty, but it's a disturbing slippery slope if you start throwing stones at "gross negligence claims = manslaughter". Hell, Rosen testified that a doc missing a PE in a 17 year old with stable VS's was "gross negligence" (it wasn't)--should that doctor go to jail? This is a system failure--you should not be able to override an paralytic med in same pixis as Versed, plain and simple. Hospitals should have a better, smarter system in place that makes this a never event. Charging the nurse for a crime is nothing more than misguided vigilante justice.
     
  7. Psai

    Psai This space for lease
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    What is an rsi pixis
     
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  8. Dr.McNinja

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    You can read the report, it's pretty clear that there are systems issues, then there is negligence on top of it.
     
  9. turkeyjerky

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    Well of course there was negligence. I doubt anyone would argue that this nurse should lose her license and never work in health care again. I also doubt anyone would be opposed to a a malpractice suit (which I'm shocked that the family stated they're not pursuing--this is the type of thing our malpractice system is ostensibly for, not the case of missing a PE in a young stable patient to when someone drops dead 3mo after visiting an ED with chest pain).

    But it seems misguided to prosecute someone for a mistake, unless there was some sort of criminal intent or impairment (which so far has not been reported). Just as I think it's misguided when, in the UK they prosecute doctors over poor,patient outcomes. Who benefits?

    Or I guess we should just throw people in prison cause we can. 'Merica!
     
  10. Siggy

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    So Dr. Murray did nothing legally wrong by giving propofol to Michael Jackson? I mean, there was no criminal intent or impairment there either.
     
  11. turkeyjerky

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    I don't get the analogy. If she had purposefully administered the vecuronium in order to facilitate the CT scan, you'd be correct. However, by all accounts she believed she was administering versed.
     
  12. dpmd

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    The issue is one of degrees. Mistakes that people could routinely make would not cross into criminal territory, but then you have the stuff that is so out of the norm as to be considered gross negligence or other legal terms that can lead to criminal charges. More controversial but sometimes it fits enough to justify charges even if there is a successful defense. Medical homicide and extreme negligence. - PubMed - NCBI
     
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  13. dpmd

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    Purposeful administration of vecuronium without a plan to breathe for the patient would be more likely to result in a murder charge. Reckless homicide is when there was no intent to kill but a wanton disregard for the well being of the patient/conscious disregard of a known substantial likelihood of injury. Not knowing what medication you pulled out of the pyxis, not reading the drug name on the vial when drawing it up, not knowing how much you administered, and leaving a patient alone and unmonitored after giving a med when if you had actually given the right med could have resulted in respiratory depression which was why the radiology department nurse wouldn't give it in the first place (because they weren't available to monitor the patient as is their policy when people get the intended med) does seem to qualify.
     
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  14. Apollyon

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    What are you questioning? The Pyxis, Omnicell, or various other names are automated med dispensers. An "RSI Pyxis" would be a secure storage for RSI meds.
     
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  15. OP
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    Dr Mantis Toboggan

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    Vandy is very good at resolving these things before any lawsuit happens. Guaranteed the family was given a generous payout right off the bat.


     
  16. WilcoWorld

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    Just dropping in to note that as I read this thread my browser is recommending I study Law.

    Curiously, I don't see any adds for safe packaging of neuromuscular agents.
     
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  17. Psai

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    just makes no sense to have a storage for rsi meds only or to store vecuronium in it
     
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  18. Apollyon

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    I don't know. It might be just like one of those mini-fridges.
     
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  19. dpmd

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    Helps keep people from accidentally giving those meds.
    Edit: though turns out they don't actually use vec for intubations there so it shouldn't even have been in a floor pyxis.
     
    #69 dpmd, Feb 10, 2019
    Last edited: Feb 10, 2019
  20. Siggy

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    Both result in medications being administered, for purposes other than what they should be used for, without adequate monitoring for hypoxia or apnea that resulted in the loss of life because of negligence. If anything, the fact that the nurse also bypassed so many additional safety checks (i.e. going to a different unit, not verifying that the medication she was administering was the one prescribed) means that the Vandy Nurse situation is worse than the Murry/Jackson situation.

    Now want to see a paralytic case that legitimately wasn't prosecuted, see the case from Bend, OR.
    Wrong drug put in IV bag led to fatal Bend hospital error
     
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  21. Dr.McNinja

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    Just so we can be clear, what is your standard for prosecution?
    What about a parent leaving their kid in a car?
    What about someone leaving a pool gate open and neighbor kid dying?
    Drinking and driving and killing a passenger?
    Drinking and driving and killing someone in another car?
    Accidentally shooting someone?
     
  22. dpmd

    dpmd Relaxing
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    The standard is defined by the laws of the state. The parent who purposefully leaves their child in the car could be charged with criminal negligence (wanton disregard for safety when harm could reasonably be predicted) but the parent who accidentally left them was just guilty of ordinary negligence which would not necessarily rise to the level of a crime. Same with the person who left a pool gate open (would have to show they purposefully left it open despite knowing someone had a high chance of falling in it). The drinking and driving automatically rises to the level of criminal negligence for a lot of states so that gets charges when someone dies. Accidentally shooting someone wouldn't usually qualify unless there was some impairment going on that caused the shooting or if you fail to call for help and the person dies from that failure. I would guess that the tech was considered to have committed ordinary negligence because they didnt bypass normal checks (like overriding the pyxis) and they passed their work onto the pharmacist to verify their work like they are supposed to (as opposed to keeping the meds in their pocket until they become aware that the patient is coding, whereas excess versed would normally have to be wasted with a colleague right after administration). Similarly the pharmacist followed their procedures but made an error by not noticing then vial was of the wrong drug and that was probably felt to be ordinary negligence too.
     
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  23. Dr.McNinja

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    Agree with most. You can absolutely be charged with criminal negligence if you brandish a weapon in a manner that someone gets shot. It's not just enough to expect that gunshots are life threatening and you need to call for help. You need to know that using a gun can result in death. Each state, again, is different I agree.
     
  24. dpmd

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    Accidental can mean a lot of things from inadvertent discharge while cleaning it (which probably wouldn't get charged if you are sober and call for help right away) to waving it around like an idiot and inadvertently squeezing the trigger during (which probably would but kinda goes along with being impaired I would think).
     
  25. Siggy

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    Leaving their kid in the car long enough for them to die? You're either talking about hours or someplace where it's hot enough to be self evident that you shouldn't leave a kid in the car. I mean, are we really going to defend parents who decide to cook their kids to death via stupidity in desert regions?

    Pool and gates doesn't require active participation on the part of the home owner.

    DUI resulting in death? Yes.

    Accidentally shooting some one is going to be on a case by case basis, but generally I don't have a problem with that. A gun going off while someone is "cleaning" it isn't an accident, it's stupidity on the part of the person who didn't clear their weapon before cleaning it. There's nothing wrong with firearms, but it takes responsibility to own it.

    Of course there's a reason man slaughter has lower punishments than murder.
     
  26. turkeyjerky

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    Re leaving kids in a hot car--generally these aren't malicious or overly stupid parents, these cases typically involve otherwise caring parents who simply forgot their kid was in the car. Obviously not candidates for parent of the year, but prosecuting them accomplishes nothing.

    You (as well as a few other posters) and I obviously have a different threshold for advocating imprisonment. In general, I don't think stupidity should be a reason for prosecution--limitation of professional duties, payment of restitution, yes, but not prosecution or imprisonment.
     
  27. Siggy

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    Where's the threshold where stupid becomes a crime then? I don't think most people go out intending to drink and drive. They go out, make a stupid mistake of drinking too much, and then while their judgement is impaired because of their stupidity, they drive and possibly kill someone. Should they not be prosecuted unless they planned to go out and drink and drive?
     
  28. e30ftw

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    Sad case that will probably result in regulations impeding patient care.

    Reaffirms something I've noticed throughout medical training; most health care professionals cannot recognize that a patient has stopped breathing and give them oxygen within 2-3 minutes. Although the prolonged time of a PET scan complicates things in this case.

    Pick through it all with an attorney's eye and point fingers while thinking, "that would never happen to me."

    We work in a specialty where you can do everything right and any of your patients can go home after a negative work up, immediately die of something completely unrelated, and you will be held responsible.

    There but for the grace of God go I.
     
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  29. turkeyjerky

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    Well personally, regarding drunk driving, I'm cool with high penalties (i.e. a felony). I think a dunk person should have capacity to know that the decision to get behind the wheel is a poor one, and dangerous. (Although I'm not sure that the penalty for killing someone while drunk driving should be an higher than drunk diving by itself, since that's really venturing into the territory of luck).

    What (conscious) criminal decision did this nurse ever make?
     
  30. Siggy

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    I think a nurse should have the capacity to know that the decision to over ride safety checks prior to administering a medicine is a poor one and a dangerous one.

    Well, I guess there isn't much of a safety check passed when a person types the first two letters of a brand name of a drug and pull out the first thing that pops up... even if the Pyxis isn't configured for brand names.
     
  31. Siggy

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    I'm convinced that most health care providers can properly operate a pulse ox past reading the number that pops up... including judging whether the number is accurate or not. I recently had an ICU nurse ask what I meant by pointing out that the pulse rate didn't match the heart rate in regards to judging the accuracy of the SpO2.
     
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  32. dpmd

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    The conscious decision not to verify the five rights of medication administration which involves checking the medication to be sure it is the one that is ordered and knowing how much you gave. Also the conscious decision not to properly waste a controlled substance after use. The nurse took shortcuts around proper protocols intended to keep patients safe.
     
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  33. Dr.McNinja

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    Honestly, if you're determining intent, drunk driving shouldn't be on the list. I mean, most people don't intend to drive home "drunk". They want their 1 or 2, and then they drink more and no longer have the capacity to make sensible decisions. However, we do (and should) hold them responsible because they made the decision to drink, which led to the ostensibly non-decision to do whatever they do.
    At least 1 doctor has gone to jail for the death of a patient they overprescribed narcotics to, and I support that as well.
     
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  34. Dr.McNinja

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  35. dpmd

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    The question of drug use (which along with alcohol use makes cosleeping more dangerous)along with the fact it happened shortly after another incident where clear doctors orders were given not to continue I think it is a legit prosecution. Makes it different than the non impaired parent that had no cosleeping issues in the past or the non impaired parent who accidentally fell asleep on the couch and something bad happened.
     
  36. Dr.McNinja

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    Correct.
    Which is to say, it's one thing if the nurse hadn't given a drug she should have known was a paralytic (or even thought was a sedative) and a bad outcome happened due to a known effect of the drug, vs a random side effect that was rare or unusual.
     
  37. turkeyjerky

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    My feeling is that she shouldn't have kids, and her other child (as well as any future ones) should be taken away. I don't think cosleeping should be a a prosecutable offense. I don't see what purpose it would serve to imprison this woman

    Back to the case at hand. Say, hypothetically, a patient receives incompatible blood due to a clerical error and dies as a result of a transfusion reaction. Should the responsible tech who mislabeled the blood get charged with manslaughter?
     
  38. dpmd

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    If they purposefully disregarded the usual protocol for labeling the blood and just slapped an o neg sticker on the first bag they saw? Yes
     
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  39. Dr.McNinja

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    Pretty much.
     
  40. dpmd

    dpmd Relaxing
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    I feel like not everyone gets our thought process. Maybe it is because I used to be a nurse and while I can't say I never messed up, i can say i never strayed so far from the fundamentals of medication administration that were drilled into us in school.
     
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  41. Dr.McNinja

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    I have the criminal law aspect, so we see the same from different sides. There's a standard. Once you meet it, it's criminal. It's not emotional.
     
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  42. Vandalia

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    I think this gets to an important point from the law. (A little knowledge is a dangerous thing...)

    There are two types of actions that government officials can perform: ministerial and discretionary functions. A ministerial act is one that an official is obligated to perform. It usually comes with the word shall. "Upon presentation of $5 and proof of vaccination the city clerk shall issue a dog license." A discretionary function is, well, discretionary. "The county engineer may issue a sewer permit."

    Courts will almost always act if an official fails to perform a "ministerial" duty. On the other hand, there is a lot of deference given to the "discretionary" acts.

    I think criminal liability for medical mistakes/errors falls largely along those lines. If you violate a shall you are in possible criminal trouble. If you make an error/mistake to a may then while you face civil liability, criminal prosecution is unlikely.

    So checking a medication before administration is a "shall." There is also little professional judgement involved: it either is or it isn't. Now lets say that the issue was that she was observing the patient but failed to observe apnea. In that case, absent other factors, it falls more on the discretionary side; while there will be civil liability, it is difficult to see bad observational skills as something criminal.

    For me that is the dividing line between the cases. If (when) standards are put in place by a hospital that every chest pain patient shall get an EKG, and a physician fails to do that and the patient later dies, then there may be criminal liability for that act. On the other hand, if a 20 yo LHP complains of shoulder pain after a game, so the EM physician does no testing based on professional judgement, and the kid then dies, then that is a civil issue.

    At least that is how I categorize it.
     
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  43. Fluffhead87

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    I’m late to the conversation and didn’t read all of the thread so my apologies if this point has been mentioned -
    There, in my non-lawyer but anesthesiology resident eyes, absolutely was gross negligence and malpractice. Vecuronium is a powder that must be reconstituted. In all the institutions I’ve rotated through, it’s always a powder in a clear glass vial. I have never seen it stocked in a liquid form. As opposed to to Versed, which is always stocked in a dark vial and comes in a liquid.
    Maybe it was a systems issue where the nurse thought that asking for clarification would result in beatings so the nurse didn’t think to as for help before paralyzing this patient but this sounds like malpractice and negligence to me.
     
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