Medication Error Kills A Vanderbilt Patient | Incident Report 203

Medication Error Kills A Vanderbilt Patient | Incident Report 203

– What is up Z Pac,
it’s your boy ZDoggMD. I’m live and direct in my office. Okay, a lot of people have messaged me including a friend at Vanderbilt
University Medical Center asking me to talk about
this thing that had been in the local press in Tennessee about a horrible medical error that resulted in a patient death at Vanderbilt University Medical Center in December of last year, 2017 and they wanted me to weigh in
on what I thought about this and initially I was very reluctant because I said well I kind
of know what’s going on here and I don’t think it’s going
to add a lot to the discussion. And then I really kind of weighed it and said wait a minute actually I think talking about this is crucially important and my Z Pac was right
and I was wrong about this. It does bear discussion. Let me back up and tell
you what’s going on. What’s up Vanessa, what’s up Suzy, I’m reading your comments today as well. So 2017 patient’s admitted
with a subdural hematoma, bleeding on the brain. A couple days into the admission they decide to do a whole body scan. I read in one of the press
articles it was a PET scan, now I don’t have inside
information about this. The patient’s name and
the involved parties names are confidential so I’m relying on press and also reports from
friends that are there that say it was as bad as reported. So what ended up happening was patient is going to get ready to have this scan. She’s expressed a concern
about claustrophobia by report and the doctor
orders a dose of Versed, which is an an anxiolytic,
benzodiazepine drug, short acting, those of us in the know know and for those of us who
don’t that’s what it is. The idea being take some of the edge off that claustrophobia, mild sedation, maybe not
remember the procedure as well, those kinds of things
which is all perfect. Very much standard of care
for this sort of scenario. Now the nurse who was
managing this patient before going into the scanner went into what presumably the Pyxis, whatever her medication
dispensing device was and couldn’t find Versed on the patient’s sort of ordered medications. Again this is my interpretation
reading the press report. So at that point she
triggered some overrides to override what was ordered and put in the drug herself. So she types in and we all kind of know how these machines work, she
types in the first two letters of the drug name, V-E,
Versed, trade name, right. Not the you know the generic name and a medication pops up, she hits okay, takes the medication. Well it turns out what
the device auto filled was a generic name which is vecuronium. And those of us who
know what that drug does know that it is a
neuromuscular paralytic agent. In other words it doesn’t sedate you, it doesn’t make you unconscious, it paralyzes your muscles,
including your skeletal muscles, including your diaphragm and
your muscles of respiration, your intercostal muscles
that help you breathe. Well, this was not a good thing because the nurse took the drug. Apparently didn’t look
at exactly what it was because most people that I’ve talked to have said that vecuronium
has a label on it, a warning label big that
says warning paralytic agent. Gives the medication,
administers it to the patient and they put her in the scanner. Now mistake number one. Mistake number two purportedly, allegedly, is that at this point the nurse or whoever the staff was who were there after administrating the drug they did not watch the patient for signs of effect or relaxation or reaction, which you’re supposed to do. Instead they put her into the scanner and then probably left the room cause she’s gonna get a scan. The patient gets a long scan. When they go to take
her out of the scanner she is pulseless and unresponsive and ended up being rushed to the ICU after I presume a code was run, rapid response and code, and she was, support was withdrawn a couple
days later and she died. Now let me just for the
emotional significance of this, let me describe what
this might have been like because what has effectively happened is she’s anxious about going into a scanner, she’s claustrophobic,
she’s already scared. The nurse said I’m gonna
give you something to relax, which is allegedly what she
said, thinking it was Versed, and effectively gave her
a drug used in executions where she was paralyzed
increasingly in an ascending way and unable to speak, but
completely conscious, able to feel pain and discomfort and fear but unable to move and
progressively unable to breathe until she blacked out, lost consciousness, presumably suffered
irreversible brain damage and later died. Let that sink in for a second. That is the tragedy in all of this. This patient died under
torturous conditions in a hospital, in a place
where you put your trust in other people to take
care of you safely. What happened? How did we betray her trust? And in the next couple of weeks I’m going to be doing a keynote at the Institute for
Healthcare Improvement talking to specialists in hospital safety and I was thinking about
this case more and more. The safety mechanisms that were in place to protect against this
happening all failed, why? And we don’t know the exact details, but in a big picture sense
it’s because a human being decided to override them and then decided that that other sort of standards of care were not going to happen, like monitoring the patient afterwards, checking on the patient,
seeing how the effect was, even if you give Versed that
can be a respiratory sedative, it can drop your blood
pressure, things can happen. There should be careful followup and watching of this patient. So on those levels catastrophic
error, catastrophic failure. Now this actually put Vanderbilt’s entire Medicare status at risk according to the Tennesseean
who was reporting on this and they almost lost the
ability to bill Medicare, which would have been catastrophic because it’s one fifth of their revenue. So they put processes in place to improve systems after this
including personnel changes, which I imagine was the nurse being fired. And again we don’t know
the name of the nurse, I don’t want to know,
this is the bottom line what is at fault here
and how can we do better? Well okay, I want you to weigh in. I want pharmacists to weigh in, what could have been done to prevent this dispensing of an
incorrect medication? I want nurses to weigh in, I
want rad techs to weigh in, I want everybody to weigh in and tell me what are you doing in your facilities to prevent this from happening. Then we want to think
about what happened here. The thing wasn’t on the order, maybe she didn’t want to call the doctor, maybe she didn’t want to have to call IT, maybe she didn’t want to get into the HR, I don’t know what was going on. Maybe she was understaffed,
maybe she was under stress, maybe something else was going on. There’s a million
reasons why the so called Swiss cheese model,
all the air holes align and you get a straight shot to disaster. Whereas normally these
situations are in place to prevent it from happening. We don’t know. Here’s the bottom line, there is no excuse for an error of this
type happening in 2018 in a major medical center. There is no excuse. And you can make all the reasons, you can say yeah this
could have been different, we could have had a process for this, we could have not allowed an override, we could have done this, but the bottom line is we should never give this a pass on any level. We need to work diligently to
figure out what went wrong. If it was pure human error
that human needs to be adjusted and whether that means
being fired, being sued, whatever that is we need to manage it. Understanding if there are
extenuating circumstances, but still this patient died
under torture effectively, all right, so that being
said, let’s back up a second. How was this different
than the story I told about the nurse practitioner who, actually I have her thing here. I have a bag of pink wristbands for
Remi Engler, her daughter, who she was, her routine was knocked off. We talked about this on the show, everything, every Swiss hole aligned where she forgot her
beautiful daughter in her car when she went to the clinic
and at 4:00 PM found her and they couldn’t save her. How is that different in terms of error than what happened here? You know in many ways
this gets to the heart of how human beings make mistakes, how we need systems in
place, we need training, we need accountability,
but we also need compassion when it’s necessary when it really was all the Swiss holes aligning
and we need to do better. Now in this case what can we do? Do we need some sort of
better dispensing process, do we need a check whenever you’re giving something like Versed, should
there be better protocols, do we need better staffing for the nurses, better support, there’s a million different things we can do. Let’s read some comments. So Emily Dial says our Pyxis, which is the dispensing equipment, also has a pop up with
this medication to warn that it’s a paralytic
agent, back to basics five rights of mediation administration. So I want to learn more about these five rights from my nurses cause, when I say my
nurses I mean my Z Pac. I want you to teach me about this because I don’t know
about this as a doctor. And actually many doctors don’t understand the medication dispensing pathway and we would probably
benefit from learning it. In my facility says Stacy Lynn
this would not have happened because vecuronium is only available in the surgical Pyxis and in the pharmacy. The hospital needs to
have better policies. So sometimes they use, you know
they can use vec in the ER, use it as a paralytic
agent along with sedation and intubation to ventilate. So it’s not an inappropriate
drug in certain settings. So I can understand why maybe
it was available, but maybe, so Celeste says triple
check, call an attending, if you’re unable to fulfill
your duties that day take the day off, there’s so many things. So I think pretty
exclusively people are saying there isn’t a human excuse for this and I think I have to agree that you cannot give
somebody a pass for this. Now when we talked about Remi Engler and I spoke to Nikee Engler, Remi’s mom, I got the sense that this
was a deeply good person for whom everything aligned
and our foilable human brains failed us in the most crucial situation. And a lot of people disagreed with me, but I unequivocally believe this because there aren’t a ton of systems to keep us from forgetting
our child in a car beyond repetition and routine and conscious awareness to the problem. But a lot of times we run on autopilot. Now in the hospital, this nurse was not running on autopilot. She had to go out of her way to override the safety mechanisms. Without then taking the extra step of making sure it was
the right medication, checking on the patient,
doing those kind of things. So that’s initially why I
didn’t want to talk about this because it’s like well it’s pretty clear, but you know what there is
always nuance in these stories and even if talking about it today changes one workflow
somewhere in the country where a life is saved or
disability is prevented. There is this whole saying that like the third leading cause of
death in the United States is preventable medical error. I’m not sure I believe the
statistic, it doesn’t matter. It’s high, it’s too high. Any medical error that causes
debility or death is too many and until we have to, guys like
part of this whole movement of Health 3.0 is looking at ourselves, putting ourselves under a spotlight saying not everything the administration does, not everything the quality czars do, not everything the
measurement industrial complex does is bad. Sometimes we need to
really focus on processes and realize that we make mistakes. So we need systems that help
us avoid those mistakes. We need better training,
but we also need fail safes. Pilots have them. There still could be human error, but it has drastically decreased and I think we can learn a lot. We don’t cookbook medicine things, but at the same time this was preventable. Let’s read a few more comments. Let’s see April Peterson
says I can’t tell you how many times I’ve seen nurses not scan the patient med,
say they’re in a hurry and will document it later
when they sit down to chart. Boo ya, that’s it. Doctors cut corners, nurses cut corners when we’re super busy
we think you know what I’ve done this so many times
nothing’s going to go wrong and then it does. And I’ve seen it happen
with potassium orders. I’ve seen people die,
I’ve seen this happen. And then the hospital
does a root cause analysis and they go through the whole thing and always it’s a Swiss cheese. There are multiple errors. Rarely is it just one human
making a single mistake. It’s usually a series of things, but again entirely preventable,
entirely preventable. Let’s see why was this drug even stocked in the radiology department. There’s a history at Vanderbilt of these sort of shortcuts, is there a history at Vanderbilt of these shortcuts occurring before? It sounds like a habitual behavior unfortunately, Marie Daniels. Well you do wonder if
the override’s that easy. You know you do wonder. Again Vanderbilt’s a
world class institution, but in our world class
institutions we make big mistakes. The bigger the institution
the bigger the mistakes. That’s what I’ve noticed
across institutions which means we need better policies. That being said if I’m
gonna have a complex surgery I’m gonna go to a major
academic institution. And again this is gonna piss
off come community people, but you want people
doing a procedure on you that does it a lot and
has a good safety record, maybe takes harder cases
so maybe more people die or have bad outcomes,
but adjusting for that they’re doing really well. This actually matters. We did a show with Dr.
Rifkin from MCG Health about care variation and saving lives and quality improvement and
guidelines and things like that. I will share it soon again. Let’s read some more comments. Yeah, a lot of, okay so
this is what I’m gonna do. I’m gonna leave you guys with this, I want you to leave your comments. I want you to have civil
discussions in this section about how we can do better. I don’t want to complain, I
don’t want to victim shame, I don’t want to blame people, I don’t want to do any of that. I want to have real, actionable ideas of how we can prevent this, what you’re doing in your institution, what you do personally
because remember this as hard as our jobs are
and as busy as we are and sometimes we feel
put upon on all sides, we have this really sacred responsibility to relieve human suffering. In this case that failed and so what can we do to live up to the meaning and the
purpose of what we do, and sometimes that
means doing mundane shit like coming up with safety protocols and processes and things like that, that seem boring but they
save lives every single day. So let’s talk about it guys. Hit like, hit share and we out, peace.

100 Replies to “Medication Error Kills A Vanderbilt Patient | Incident Report 203”

  1. PICU nurse here at the children’s hospital of Philadelphia. Something like this could never happen in my unit unless you were directly breaking rules. We can override in our pixis but we dont override controlled substances such as midaz. Furthermore both midaz and vec are two clinician independent checks on the five rights. Even further you have to scan out medications prior to administration and then check against the order in the MAR. These safety checks should be done EVERY TIME. This mistake just isn’t excusable.

  2. ICU physician here, what's really interesting here is how you compared the two incidents and decided to give a free pass and lots of sympathy to the nurse practitioner simply because you have communicated with her, listened to her story and established a human connection which resulted in an understandable human sympathy, however this judgment was unfair to the nurse because neither you have the full facts of what happened nor have listen to what she has to say. Make no mistake I personally believe that the nurse had committed not only a mistake but it was an act of negligence and malpractice resulted in a horrific patient death but it was as horrific as the nurse practitioner leaving her four years old daughter dying slowly in the car.

  3. RN- Many things about this scenario are questionable to me but simply put it sounds like complete breakdown in standard of care. Clearly she was not familiar with versed or she would have been able to locate it appropriately. We have a responsibility to our patients to always be familiar with medications we are to administer. Ones we might not be as up to date with takes a simple call to pharmacy or asking another RN. No way I think about this adds up though. Only thing that I can imagine is extreme sleep deprivation. Long hours and people have families to raise, so who knows what hours she was working prior to this and how much she had slept. In her head maybe it read versed?

  4. Rn here, perhaps second RN sign off med dispensing machine, as well as second RN sign off upon admin. We scan our meds prior to admin, high alert meds for the most part require second RN approval and sign off on MAR, sure pain in the butt but safer practice = better outcomes!

  5. As a student interested in medicine, and who has undergone multiple medical procedures – I agree totally with what you said. I personally think that, this really boils down to personal responsibility. I'm not saying that this nurse was a bad nurse, or that she didn't care, but, we, as a species, need to pay close attention to matters such as this. If someone believes that they're having an off day, as I believes this nurse may have been having, action needs to be taken, whether it be a day off, or taking a break for a few hours to get your head back in place. I agree totally, and appreciate the analogy to airline pilots. In the end, it boils down to people's lives being placed in the hands of the medical staff. I was fortunate enough to have great care when I was taken care of, however, I, being inpatient for several years, as well as volunteering at medical institutions, was able to see behind the scenes to a certain degree, the stresses that befall all staff, doctors, nurses, and other staff alike. I understand that it might not be an easy task to perform these duties, however, its also important that these duties are done correctly, and with the full attention of staff. I hope that I'm qualified "enough" to make this statement, but if you, the reader, doesn't believe that I am, feel free to dislike, or comment. I'd love to hear any supporting, or dissenting opinions. Discussion is what makes things better, and I'd like to be more informed on what the opinions of others are, so, "let 'er rip."

  6. Nurse here…
    I can't believe this med was in a Pyxis! How is it that this med could be overridden? A disaster waiting to happen!

  7. Physician here.
    – First: I hope the nurse who made this error is provided with emotional and professional support. While from an occupational standpoint it’s unacceptable, what is done is done, and as a person she will probably need a lot of help overcoming this tragedy.
    – Second: This is a good time to emphasize the value of a two-person system regarding medication administration. When doctors order medications, they have a nurse double-checking those medications and calling back if there are questions. Many a nurse has saved an intern from making a medication error. But when a nurse directly orders a medication under a doctor’s name, they don’t have that two-person advantage because they are the last step in the process before the medication is given. There is no second reviewer. So perhaps when nurses order meds under a doctor’s name, two nurses should be required to sign off.
    – Third: certain medications, such as vercuronium, should require a higher level of authorization for retrieval. This error was a human one, but I also feel the system failed the nurse as well. Error messages pop up so often on the EMR that we get desensitized to them. So while she probably clicked through error messages and might have done a manual override, it should not even be possible to make a mistake of this magnitude.

  8. It seems that if you are over riding a medication in a pixis then there should be a sytem designed where two nurses would have to over ride a pixes.

  9. I think as healthcare professionals we all need a change in how we function! We need to be able to slow down at times in order to focus on the task at hand! So often we are expected to rush through scenarios such as giving meds that in nursing school are taught by giving us ample time to verify the 5 or 6 rights and then plenty of time for patient assessment! In the real world, these pre and post assessments can not happen if you want to be able to keep your job! Not giving this nurse a pass as she did not do the one thing we all should do which is verify the right damn drug and patient! But we work in this super high paced field that doesn’t even teach us how to function when overworked, understaffed, or stressed out and let’s face it, that’s our reality! If hospitals feel comfortable with their nurses functioning like this then let it be reflected in the nursing schools from now on! You’d have a hard time finding nurses to finish the program! I think in an attempt to keep costs down, our medical facilities have sacrificed patient safety and let the burden be carried by nurses, doctors and other staff who are held responsible for such errors when they occur!

  10. This happened in Canada.
    Not much info out there yet.
    How would the parents not see the aftereffects of bringing this baby back from cardiac arrest (It's rumoured they weren't told about the mistake for some time).

  11. There is a simple solution to this tragedy. Veccuronium shouldn't be an override option, not all drugs are just emergent drugs. RSI kit, should be an option. Then correct use is not hindered but this mistake is avoided. A terrible tragedy and a simple solution.

  12. Three words: Mandatory Staffing Ratios

    I don't believe there are many further technological interventions that can improve the safety of med administration. No matter how many computers get involved, I will always be the last line of defense between my patients and a medication error. My hands, my brain, my responsibility. There's no way around that. (The "five rights" are just a fancy way of saying "pay attention to what you're doing every single time")

    But the one thing we can do for all nurses is to put legal requirements in place to make sure they are not so understaffed and overburdened that we make it impossible for them to perform their jobs safely and correctly . Here in Mass, we just lost the fight to pass staffing ratios to a poorly written ballot measure and overwhelmingly well-financed (and largely dishonest) opposition from hospital systems. But it needs to happen and it needs to happen for the entire country.

    Yes, this will cost money. But no one ever argued that we should forego safety measures in an airplane because it was going to be expensive. The same standard should apply to health care facilities.

  13. In my experience most of the time we are understaffed with a full patient load. With that being said if i feel weird about a medication or it needs an override i ALWAYS double check it with my charge nurse or someone with more experience than me before i give any high risk drug. it’s hard not to get in a hurry sometimes but that’s when errors like this happen.

  14. You u derstand the humanity of the NP because you talked to her. Talk to this nure. She is a wonderful, kind nurse. Her state board of nursing cleared her. The hospital has thrown her under the bus.

  15. This woman was my great ant and she was talking about Christmas before she passed and the irresponsible nurse decided to give her the wrong medication I and my family are still devastated one year later.

  16. This is really sad (for the patient, family, and nurse). I stopped working on the floor because, among other reasons, it seemed like support kept being taken away from the RN yet more tasks were being added to the RN duties. My hospital’s favorite saying is “the RN is the coordinator of care, hence making the nurse feel unsafe, which is one of the reasons why I walked away from a job I loved and still miss three years after the fact. Hospitals need to stop looking at only the dollar signs and listen to their frontline staff/the people actually doing the work. If the people making all of the money while they sit behind a desk and make decisions would come out and do some patient care, maybe they would make better decisions.

  17. Whomever allowed vec to be overridden (director of pharmacy) is complicit. Also if the rn gave what she thought to be versed, a doc is supposed to be in the department (common hospital/ACS policy) and pt is on continuous EKG and spO2

  18. I’ve always learned that you don’t give Versed to someone who may have or suffer from a neurological insult or deficit. So perhaps the initial order wasn’t even the best.

    Also even if she was allowed to override the medication, most hospitals have gone to a scanning system where you scan the patient and the drug, at that point she would have realized the wrong med was selected. But it sounds as if the original order wasn’t even on an electronic medical record hence she needed to override from the Pyxis.

    Our hospital will not even allow verbal orders anymore or written ones for that matter (it isn’t protocol) to clear any possible mistake or confusion.

    So perhaps there is some responsibility with the physician as well.

  19. Why not call pharmacy and ask, hey, why isn't Versed showing on this patient's med list? Can you please verify it for me so I can pull it?

  20. Doc Z the working conditions in the Midwest for health care workers are so harsh… staffing ratio is so bad. I had worked in the Midwest for 13 years as a nurse and now here in California as a nurse for a year now. The working conditions there in the MIDWEST is not safe for the patient and definitely not safe for the nurses. I had seen a very hugeee difference as to how it is so different safety wise. It is a NIGHTMARE.

  21. A couple of thoughts from an engineer and an EMT:
    * Medications which have a high likelihood of causing immediate death should require 2 people to sign off. We already do it for blood products. We should extend that to paralytics and IV potassium. There should also be a review of other drugs like IV insulin for possible inclusion in the list.
    * People tend to follow the path of least resistance. If an "override" is selected, it should require something painful like a 5 page essay on how and why this action was required to be written. This way, when the choice is between "annoy the cranky attending" or "write a 5 page essay", dealing with cranky staff will be the easiest to do. People will only be willing to put up with the paperwork requirement if there really is a life on the line.
    * Likewise, the concept of an "override" generally means that the existing system wasn't set up to handle all relevant possibilities. This is perfectly reasonable. But if people get so used to doing so, they encounter error message fatigue and it only serves to provide a liability shield. If an override is used, there should be a review by all relevant departments to understand why it was required and how that condition might be added to the regular workflow.
    * Why wasn't a patient supposedly given a sedative not on at least a pulse oximeter? Over-sedation and mild hypoxia are common side-effects of benzos.
    * Why didn't the rad tech notice/say anything? If proper procedures were routinely followed, the rad tech should have expected a nurse with an epi-pen to be hanging out for at least 10 minutes. Likewise, if someone is being given a benzo they should have at least been on a pulse oximeter. I have the most sympathy for the rad tech because ensuring that a different person with a different skill-set performs their job correctly is an unreasonable expectation. At the same time, I'd be interested in knowing why they didn't notice or suspect something. Was the nursing staff routinely giving benzos and not sticking around for follow-up? Was this just a new rad tech who didn't know the flow at that hospital? No blame to go here, but possibly an additional avenue for safety.

  22. The only human error I can think of is that the vecuronium was placed in the versed spot that might explain not seeing a notice for paralitic. I see these paralitic in the ICU, ER and OR for intubation. Requiring a witness when getting these meds?

  23. With the human nature to trying to make our work easier and faster , I’m amazed it doesn’t happen more often. The Pyxis shouldn’t be able to be overridden except by a pharmacist. Not the nurse delivering medications.

  24. There were many chances to catch this mistake before it was made. Mistakes usually occur from a sequence of small errors that are overlooked. It’s always good to stop and double check what you are doing… a few extra seconds can make a big difference!

  25. I am sorry this nurse is facing criminal charges. However, this egregious error (and it was egregious, make no mistake about it) was not a systems error. Yes, the patient should have been monitored and wasn't for whatever reason. Yes, being a float sucks. Being a preceptor sucks. But none of that was the cause of this patient's horrific death. The case was due to something that gets beaten into every first-year nursing student: Right drug? right dose? right route? right time? right patient? And some even add a 6th: right indication (we can't give improperly-prescribed medication). Let us not bleat about forgiveness by the dead person, collapse of the system, just culture, or under-bus-throwing. Not applicable here. There is NO excuse for her not checking the medication vial before ever drawing it up. Let alone for the moment that vercuronium shouldn't be available anywhere to anybody who's not qualified and prepared for intubation, that there should be a BIG BEAUTIFUL FLASHING LIGHT: Danger, Will Robinson! OVERRIDE!, that she didn't check the patient for the effect of the intended sedation (another basic fail). If not for this nurse's failure to do the most basic med procedure, this patient would not have rec'd the drug that killed her dead. Full stop, the end. If you run a red light and kill somebody, you're guilty of a criminal act regardless of how awful you feel about it. This was a big honking red light she ran; this was an act of criminal negligence.

  26. Registered nurse here with years of experience in the Emergency Room. I am and always have been very passionate about patient safety. There are so many things that were missed in this tragic situation. As a nurse, I know that mistakes happen. However, my initial thoughts 1) In my experience, vecuronium is a powder that has to be reconstituted before given. Not sure if it comes in other forms but not that I've seen…. Which made me wonder how the 2 drugs could be mistaken for one another (despite starting with the letter V). 2) My heart just ached at the thought of how this lady died – knowing how this medication works – just brought me to tears.
    With that being said – Do I think this error was made with malicious intent? Absolutely not! Do nurses have a due diligence to take care of their patients to the best of their ability? Yes they do! Nurses carry a lot of responsibility on their shoulders day in and day out and that task is sometimes very stressful. I know that this young lady is devastated by what has happened and that is something she has to live with forever.
    Ive read so many articles on this case and it saddens me to see how many people are judging this lady. I'm not perfect and I'd definitely not God so I will leave that up to Him. However, I do feel that people are trying to blame nurses being over worked and under paid instead of what really happened. The facility had safety measures in place that were not followed and that needs to be addressed. Those hard stops and safety measures are in place for a reason. I have said for many years that we as nurses need to go back to the basics. This is very unfortunate for everyone involved and a lesson that can be learned by ALL.
    I pray this young lady is able to deal with the emotional challenges this situation will cause for years to come, that she learns the valuable lesson that comes with it and is able to forgive herself and move forward. I pray the family of the patient is able to have forgiveness in their hearts. This didn't just affect one person, there are many, many people that have been hurt and their lives have been changed forever.
    Although I know that nurses are spread way too thin at times, I also can't wrap my mind around the fact that so many things were missed in this situation – things that were in place for a reason.
    Such a tragedy all the way around – but I feel like it could have been prevented.

  27. As a nurse, I often had to override medications working in ICU unless I wanted to make my patient wait probable significant amount of time to get it. If the Pyxis is like the one where I worked, Versed probably didn't show up under the patient's name because it was a STAT, singe dose order and was not yet officially ordered via some kind of documentation by the MD and therefore not yet confirmed by the pharmacy and updated in the Pyxis. Her avoidable mistake was to not read the label on the bottle prior to administering. I also agree that there is no reason for vecuronium to be in the Pyxis and there should be safe guards for high alert medications. However, I feel like there are a lot of things in hospitals that put patients at risk that don't have safe guards in place. One main on that comes to mind is unsafe staffing causing high patient to nurse ratios. My point being is that many things need to be addressed to ensure patient safety. The bottom line is simply that she should've read the label.

  28. He mentions the med given is used in euthanizing so why would that medication even be available for use in that setting, and as dangerous as it is why doesn’t it need to be second checked by another nurse before administration. Some Pyxis machines won’t even let you take out a tramadol without a second person verifying you…

  29. Here is my question. Don't you have to mix the paralytic with saline. And you do not have to mix versed which if you take out all the other wrongs that would be a big indicator that it was not versed ?

  30. Im a cticu RN and 2 minutes into this before you even confirmed what happened i knew. ive never felt so disgusted towards another human being. In nursing its common practice if u dont know what you are giving you DO NOT GIVE IT, that being said vec comes in a vial as a POWDER, it has to be reconstituted with 10cc of sterile water and there are multiple areas on the cap that say paralyzing agent. Versed is a 1 or 2 ml vial, it literally doesnt make sense how she had to MAKE the push of vec and administer it before she realized hey theres alot of steps for this. She went above and beyond and put effort into killing that patient

  31. Use GENERIC NAMES for medication!! This is such an issue that really irks me. It’s impossible to know all the trade/brand names out there. Using generic names cuts out the possibility of confusion in that sense. Registered Nurse here and I’ve seen it too often.

  32. I work in Anaesthetics in Australia, and am very familiar with these drugs. So many issues here, but for me not monitoring the patient is the real crime….

  33. Kudos for admitting that as a MD you don’t know how Pyxis works.
    As an RN, (and a new nurse) critical thinking on every med we give is crucial. I learned the hard way giving metoprolol (a common f-ing med) to a patient with low bp, and he was sent to icu. He survived and honestly still loved me as his nurse because of my compassion (I was not judgmental of his lifestyle).
    But I now double and triple check everything. I’m slow with med pass, but I’m safe.

  34. holy cow, what a dumb nurse! I'm sorry but everyone knows you triple double check! What happened to the six rights??? She deserved to get her license taken from her.

  35. Paralytics are kept far away from the pyxis where I used to work. They were only in the ICU, kept in a separate medication fridge in a different box called a "cold-kit". These meds are highly regulated and only given by ICU or ER nurses and doctors.

  36. When my son became a T1 diabetic at 11 years old, the entire situation was a mess of miscommunication from the get-go. The worst was on day two at lunchtime.

    A nurse came in, gave him his insulin shot while he was eating and left.

    About two minutes later a second nurse came in to give him a shot. I asked what it was and she told me insulin. I objected that he'd just had his shot. She misunderstood me and thought that I didn't understand that he needed a shot for every meal. She began to argue with me, explaining that he was going to need insulin for every meal for the rest of his life, and I argued back and tried to explain that I got that he needed more insulin, but that he'd JUST had insulin a few minutes before.

    The stress of the situation was thick in general and my poor husband was at the end of his rope. He became angry with me and told me that I wasn't a damn doctor. To stop arguing and let the woman do her job. While he and I were fighting the nurse moved forward to give the shot and I actually screamed. That got her attention. At that point, I started yelling my head off, desperately trying to get it through her thick head that she was giving double the dose. All the while my husband's yelling at ME. (Funny that, at one point, he told me to stop being so emotional. lol!)

    She finally gets exasperated, turns to my son and asks, "Did somebody just give you a shot?"

    He's sitting there with big eyes, scared out of his mind, and says, "Yes."


    "Right before you came in. Right here." He points to his stomach.

    Finally she frowns, excuses herself, and steps out of the room. A few minutes later her and the other nurse come in and apologize.

    Nurse A gave the shot. She stepped out to log the situation onto paper. Then she had to log the information into the computer. (The hospital had redundant systems at the time) In that time lag, Nurse B checked the status on the computer and saw that my son hadn't had his insulin yet. For all we know, she could've glanced at the system tracker while the shot was being given.

    This situation bothered me on twenty different levels. At the time I had no idea what would happen if he got twice as much insulin as required. This was all brand new to me and I just knew it was bad. But later it occurred to me that this may have happened to other much sicker people and possibly with much more dangerous drugs. That little lag in the system left room for a ton of errors for a busy team. What upset me was that the nurse had such perfect confidence in her system that she couldn't hear a human being who was trying to correct what she thought she knew.

    In retrospect, I wish I'd told somebody. The nurses did nothing wrong, it was a flaw in the system that nobody realized was there and I had no desire to get anybody in trouble. But this flaw could've hurt someone very badly. Sadly, I don't think that anyone would've foreseen the problem until something very bad happened.

    The problem is that systems are designed and operated by human beings. I don't know how to get around that.

  37. An obvious contributing factor here is that autofill is not intelligent. Why is autofill allowed to suggest black box drugs? With everything else that went wrong here, a simple filter on autofill would have prevented this. (And when that class of drug is really needed, spell it out.)

  38. I have to say that that med should not have even been in the pyxis cause it is a paralytic and can be fatal, plus she obviously did not check the label on the med vial. We had versed on the floor but not paralytics, it might have been in the crash cart for intubation but not sure. Plus the hospital obviously did not have a protocol when administering versed.

  39. No, this should not be a criminal error; however, it is an egregious error that should not have been committed. ALL MEDICAL PERSONNEL should LOOK AT THE LABEL before they administer ANY drug. It only takes a moment. MAKE IT a habit. No doubt the error would have been recognized had she seen the word "vecuronium" instead of "Versed". Vecuronium is a neuromuscular blocking agent used in general anesthesia AFTER the patient is asleep to effect one thing: muscular paralysis. It does nothing else, including altering the state of consciousness. I would not wish that on anyone. MAKE IT A REFLEX ACTION — PICK UP THE VIAL/SYRINGE/WHATEVER AND READ THE LABEL.

  40. To my knowledge, this nurse was floated to the neuro icu. Also, I believe vec must be reconstituted and versed is liquid in an amber vial. No reason this med should have been confused. Vec is used mostly in ER, ICU, and OR

  41. Critical Care RN here, from what I understand she was floated to the Neuro ICU, if she was versed in critical care she would have surely known the difference in the two drugs. I would think she may not have the critical care acuity to have worked that area.

  42. Right drug, right patient, right route, right time, right dosage. Two rn confirmation of certain drugs like insulin n heparin used to be a standard. I double check with any drugs I am not familiar with in giving. Also if I cannot find something in the list of meds in pyxis, I call pharmacy. Do we know if rn involved was a floor nurse who took meds to pt in radiology without a scanning station? Because scanning a wrong med would show up there. Also I would have involved the charge rn with this weird request.

  43. As a nurse…..some i know are horrible when it comes to pharmacy, drugs etc. Read people. Know the stuff you inject in your patients!

  44. We need to stop and try to look at this from inside the tunnel to try to understand why the nurse made the choices she made. Also I think that the Just Culture algorithm needs to be applied. Most importantly the organization needs to reevaluate systems in place that allowed all the barriers to fail allowing the holes in the cheese to align.

  45. Rad tech here. Patients are often dropped off in radiology or MRI and then left unsupervised. That is fine to a point. However the tech must be informed if the patient has been given a drug that will seriously change their behavior or condition. If you are performing a exam and the patient stops responding that is a good time to call a code. Meanwhile if a patient is receiving a drug (pain medicine or sedative) it should be working before the exam begins. Why even administer a drug for anxiety if you are going to start the exam before the drug is in effect? Same true for pain meds. If they had done that they would have seen that the patient was completely unable to respond. We can't monitor a PT in a MRI for changes in condition. Sure maybe the pt stops talking but many people fall asleep in the MRI. So it is up to the tech to ask, "did you administer a sedative/pain medicine/any other drug before the exam and is that drug in full effect?" It's basic patient hand off.

  46. I'm a nursing student, two months out from graduation, there are 6 rights now : Practice the six rights of medication administration
    Right client.
    Right route.
    Right drug.
    Right dose.
    Right time. These are all well and good, but stress and short staffing among other things all come in to play, it's scary, but it's also reality that these things happen.

  47. Something similar happened at a hospital nearby…

  48. Human Factors literature: "Alert Fatigue" – esp. combined with the culture of that place, the stress of nurses, etc. It's completely possible that a pop-up was not "seen"…


    How is this so hard. Even ZDOG seemed like he couldn't remember generic name Midazolam. Brand names are only used so the PATIENTS (read: layman) can remember their prescriptions. No healthcare professional should ever be using a drug company advertisement to describe a patient's drug regimen. It is a huge source of confusion, especially among midlevels and nurses who don't have a strong pharm background. Sugar is sugar is sugar. I don't care what the brand is and neither should you.

  50. Even the best make mistakes of some kind everyday. As we roll through the day no one remains perfect. Just because our mistakes didn't injure or kill doesn't mean it couldn't. Everyday tasks such as driving kill people by the millions every year.

    Unfortunately an innocent person was killed in a torturous way. It is a tragedy for all involved. That nurse had to live with that now. You know she didn't mean harm.

    That said, I find it a good practice to always look at the medication bottle to confirm the right med and dose per vial. Override or not. Know why you are giving it of course. There is nothing wrong with checking yourself even when you are sure. Never let anyone push you to give it without being sure of the med rights. Many situations require an override. Check yourself before you wreck yourself and someone else.

  51. Nurse here. required video for this months inservice. First I'd like to say that this scenario is what absolutely terrifies me about being a patient in any hospital today. When I graduated from nursing school almost 40 yrs. ago, one of they greatest terrors was making a medication error. The instructors drilled into us over and over and over again, the five Rights in giving any medication is essential. Unless the medication is mislabeled by the pharmacy, there is no way to make this error, especially of this magnitude, even if the drug is in the wrong drawer. This nurse was ignorant and neglectful and killed this patient. The system is not responsible to absorb the blame, nor can we make any system involving human beings 100% fool proof. People have to be accountable and that means learning the basics and minimum standards BEFORE the role of practice. The consequences are too great. The few good things about the charge machine (aka pixus, is a PIA, and delays patient care) accounts for billing the appropriate charges alleviating that responsibility from the nurse and at least holds physicians accountable for documenting their medication orders, that all too often were verbal, and occasionally denied even after being given, leaving the nurse to hang. No nurse worth her salt could make the mistake between Versed and Vecc. The system, and the need to expedite, is to blame because its taking the place of basic nursing!

  52. Vanderbilt has a big problem of cutting corners . We have so many unqualified people training unqualified people with bad habits and Vanderbilt only cares about how you haven’t offended someone you had to correct . The ones who uphold basic standards are often pointed to blame

  53. Did she not realize that the pyxis would pull up generic names instead of brand? Also, did she not even look once at the medicaton she pulled form the pyxis? You're supposed to check it 3 times, but if she would've read the label ONCE she would've realized it wasn't Versed.

  54. Also, how experienced is this nurse? Does she have a reputation for incompetence such as med errors etc.? What was her patient load that shift? How many hours had she worked? Had she been mandated and working over time? These are also things I'd like to know.

  55. Nurse here. Why on earth is this med in pyxis? Look alike/ sound alike meds are definitely safety concerns. I can't tell you how many times I've gone into pyxis to take out a med and found either a different med that I was looking for OR wrong dosage amount. How many errors occur without us even realizing it?

  56. I agree that the nurse screwed up.

    Usually I’m inclined to believe that we need to blame systems and not staff. But this was poor judgment in so many ways.

    What I heard about the case was this nurse wasn’t experienced with giving versed. So she probably didn’t even know what vecuronium was (maybe assumed it was another name for versed).

    I’m a step down/med surg nurse and had never heard of vecuronium (?) before.

    I’m thinking hospitals should have mandatory medication training for all nurses, no matter what unit they work on. Nothing intensive, like pharmaceuticals 101. But basically an overview of the high risk medications that have most contributed to patient injury and death.

    This would include some info for non-critical care nurses about what meds they shouldn’t be messing with unless they’re specially trained

    If that nurse had known better, she would have refused the assignment in the first place.

  57. The nurse is the only one at fault here. The nurse overrode a medication, did not select proper medication, pulled the vial on the wrong medication, drew up the wrong medication and gave it, then did not monitor the patient. Nurse should be held at fault medically and criminally.

    We had a nurse give the wrong medication to pregnant woman. We have policy in place, one nurse has to sign off getting it from Pharmacy, two nurses have to then sign paperwork at bedside with the patient, she by passed all this, gave the medication to the wrong patient and killed her baby. The nurse was not penalized in anyway, we actually had meeting to say, "this should not be a punitive manner." Thats bull crap. The person bypassed multiple safety measures willfully because she wanted to get to lunch with her friend.

  58. JD RN here. Horrific. no excuse. Please do understand while not an excuse, RN's are rushed constantly to do multiple things with multiple interruptions. Absolute safeguards should be in place with potentially lethal drugs. Warning labels flashing colors and parameters (enter BP for BP meds), protocols for witnesses to co sign for certain medications being pulled and administered, protocols to stay with patient for certain medication administration (like with first 15 min of blood admin). We have to cosign heparin now. NO ONE should be able to override and pull a paralytic this easily., With all this technology the big picture of basic care (input/output, monitoring patient etc.) is being lost and the focus is on checking boxes and moving more quickly than is safe at times. So very sad.

  59. I'm a pharmacist and I am very surprised that the hospital doesn't require that when an override comes up, another person isn't required to approve the override. If 2 people look at the order and the medication being removed from a dispensing machine, error rates should be eliminated or at least decreased significantly! I am in agreement with Ann Marie K, I don't think that paralytics should ever be in a pyxis machine! In addition, drugs should be always referred to by their generic names. This nurse obviously ignored many safety stops. She did not read the label, she did not heed the warning on the label that warns that the drug she had removed was a paralytic, she did not compare the drug with the physician's order, and she did not double check with anyone else on the unit. I know that healthcare workers are busy, but there are usually some people around that can help verify that a drug is correct. Everyone makes mistakes but I think that mistakes are lessened by another pair of eyes.

  60. the "rapid response team" in the hospitals ive worked in are nurses, I don't like that, the hospitals don't want to pay for doctors and are placing peoples lives in the hands of nurses that don't have the training, schooling, and clinic time that the doctors have. The billions the hospitals are making apparently isn't enough for them so they are cutting out the doctors in important areas .

  61. I was in a coma years ago.. i could hear and feel everything. This story took my breath away, & tears are flowing. I know the fear in being aware but also being unable to move or speak in any way. I could hear and feel the procedures done. That's terrifying having an idea of the terror she went through. I agree the error needs corrected, 100%! Man, I need some wine after this video.

  62. 5 rights weren't done. Part of that is checking that medication label 3 times before anything else. And this concept is pounded into our heads in nursing school. Or it was…

  63. Zdogg. I work EMS in North Carolina. We have a protocol that I would like for you to discuss. When it comes to RSI, in Robeson County we cannot give Lumbee Indians succinylcholine. Apparently they cannot metabolize it at the appropriate rate. It can stay in their system for 2 or more weeks. In the contraindications for the drug (NC) Lumbee Indians are listed. I'm curious as to whether or not you have heard or this? Thank you for your awesome work! I look forward to hearing your thoughts on this!

  64. You have got to check and double check, triple check. This is so sad. I am a patient, not a nurse, or other health care provider.

  65. There should be barcode scanners at CT. I’ve given morphine and zofran once for a pt who was in pain. Boy did I triple and quadruple check my 5 rights since there wasn’t a scanner. Scary moment.

  66. Enough guilt To go wrong
    Monitor ing & pulse ox
    Any drug STORE in america🇺🇸
    Has all pulse ox for under 30$:
    No monitoring NO. PULSE outpatient dialysis. NO PULE OX Monitorig NO PULE OX LESS TAN 35$ APULSE OA EREFILL

  67. my daughter was killed like this in a California hospital. I caught a nurse grinding TAB 12 hour time release morphine into this freshly placed feeding tube while my daughter was SLEEPING. She was in no pain that day so she didn't even need pain meds. This nurse too had to OVERRIDE THE POPUP WARNING THAT THE DRUG SHOULD NEVER BE GROUND. this overdose tanked her blood pressure to 57/20 within 60 minutes but then the nurses start fentanyl? My non-terminally ill 26 year old daughter was dead in the morning 12 hours later. Months after her death, i wondered how that TAB morpine even got into my daughter's room. I noticed then that it was not just ONE nurse grinding morphine but a TEAM of VETERANS SEEMED TO HAVE NO IDEA NOT TO DO THIS? These nurses also falsified the medical records recording that my daughter had taken these pills whole. My daughter also had diagnosed gastroparesis and ileus (caused by too much unnecessary morphine) which makes this TAB morphine even given whole a potentially fatal overdose per its drug label warning. Then i noticed that my daughter was also given what looks like a fatal dose of fentanyl and a propofol and the doctor put her in a theraputic paralysis then extubated her?!? what the hell is going on in hospitals?!? thank you for voicing how wrong this is to do to vulnerable patients that cannot protect themselves. None of this even looks like a mistake to me. She entered the hospital for gastric distress and hypOtension, she was able to walk and eat and during this hospitalization all that is stripped from her and then she was just euthanized against her will. Thank you so much for being a DOCTOR AGAINST THESE PRACTICES – MY DAUGHTER TOO WAS ALSO TORTURED TO DEATH. WHY?

  68. As far as the claustrophobic part, there are open scanners , if the patient had been referred to one, no medication would have been needed . " Such a tragic incident "

  69. Besides a visual warning perhaps add an audio alert to accompany critical medications.Diasable the ability to over ride the system.

  70. There is only one thing you have said that I agree with. This was a terrible mistake, blame this on what or whomever you will. But what has Vanderbilt done to prevent this from happening again?

  71. Unclear..
    So was Versed actually ordered for this patient?? So the nurse simply decided she should have Versed??? Sorry if this is the case… there was NO order to give this medication in the first place!

  72. Hi, A retired ICU nurse now living in Las Vegas. In ICU where I worked we had a protocol in place – before we could removed potent medications in the Pyxis like paralytics, versed, fentanyl etc. we needed a second RN verifier before the medication can be dispensed.(A good balance and checks especially for the ICU nurses who is always in a rush) We are not allowed to override medications with the Pyxis until approved by pharmacy and a doctor's order in place. We have to call pharmacy and they will put the medication in patients profile before we can pull the meds due to a previous fatal incident. Now, my question- Was patient admitted to ICU or ER because if that is the case the patient should have been attached to a monitor and the nurse would have detected early vital sign changes. We also carry a lock box containing Narcan, Romazicon to reverse extreme sedation. Versed is normally used for a procedure bedside but not for anxiety. It is too potent. Dilaudid is a better choice. Paralytics are not available in other units Pyxis. The 5 R's are right meds, patient, route, dose and time and performed during the removal of the meds in the Pyxis. Both nurses have to agree and second verifier puts her own code in the Pyxis. This is a very good protocol in my opinion. The nurse in this incident committed two errors, first overriding medication without verifying with another RN to ensure it was the right medication. The second error was (I would conclude patient was in ICU with her diagnosis) she was not looking at the monitor because she would have noticed the changes.

  73. I think if your going to override a medication system, there should be two nurses that sign off on this. To verify that, ok yes we know your overriding this medication and yes it is the CORRECT medication that you will be administering. This whole thing is just human error. Your life is in someone's hands, pay attention, don't get too comfortable in your job, follow procedures everytime. No excuse for this.

  74. I find this video very interesting in contrast to your ‘moral injury’ video. The mistake was preventable. Yes. I think there is no question on this. The thing to remember though is we are all human. It has to be possible to override computers when they tell you xyz. Problem is, as humans, we do the same thing over and over again, the protocol becomes meaningless and actually gets in the way of safety. How many times have I seen in these threads people complaining about ‘busy work’. All that busy work was put in place for a reason, checks, and double checks and documentation. My concrete suggestion to add — maybe something like they apparently do in airport security where they will superimpose suspect objects on luggage scans to keep people alert. Have the machine error on you sometimes, print the wrong drug name on or something like that (but drugs and instructions are all right so if you miss it patient care isnt compromised). You pick up on it — you get a bonus. (You miss it, there is a review to determine why you missed it)

  75. YEAH, WE HOPE, she was fired. She should've been PUT IN PRISON!!! This was COMPLETE, and UTTER NEGLECT!~!!! Let me tell you something. YOU for one, NEVER even think about administering a medication such as Midazolam without monitoring, of ECG, Blood Pressure, Pulse Oximetry, End-Tidal Carbon Dioxide, and patient assessment. NONE of that was performed. And, YOU SHOULD NEVER, EVER, EVER, EVER administer a medication without CHECKING THE MEDICATION LABLE, RE-CHECKING, CHECKING AGAIN, CHECKING AGAIN, and CHECKING THE MEDICATION AGAIN!!!!!! VECURONIUM and VERSED, are two different medications in the Anesthetic category, only VECURONIUM is a NEUROMUSCULAR BLOCKING AGENT!! This nurse I hope was sued for more than everything she had. Seriously, this nurse, How in the world did she get through Nursing school?

  76. i dont have inside info on this. so u have some thing less. could.leaving child in car was a despence problem. care not needed just some practice of some sort.

  77. Excuses dont get it…
    Upper cumberland area agencies should be ashamed of covering ass…Should be more concerned about taking care of med/patients..

  78. Waze app warns you to take you children out of the car when stopped.

    I wonder what time of day the mistake was made. Afternoon perhaps?

  79. Why were they keeping paralytics in a cart that could be overridden if they aren't performing surgery in that department? What were the staffing circumstances that day? Was she experiencing warning box fatigue? These are all important questions to ask. By the way warning box fatigue is a well studied and verified issue in healthcare.

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