Nurse kills patient by giving vecuronium instead of versed

[fakin' the funk]

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

The ED is dangerous because the patient had myoclonus?

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[Aether2000]

At my hospital, anyone receiving Versed is placed on a pulse oximeter and monitored, anywhere in the hospital. These nursing series of errors caused a terrifying horrific death to a human.

 

[VA Hopeful Dr]

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

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

 

[Mman]

was this on purpose?

yes but the physician ordering it had no idea the patient would stop breathing and the nurse didn't know either. A code was called and the patient intubated and somehow didn't die.

 

[CopaceticOne]

At some of the hospitals I work at there are both Pyxis and MedSelect machines.

On the Pyxis you can enter generic or brand names and get the right drug.

On the Med select, there is only 1 enter possible per drug, so everything is generic names (or really weird in the case of epidural solutions in PACU - “narcotic miscellaneous”).

In looking around, almost all of the ICU & floor dispensers are MedSelects. In the ORs we have mostly Pyxis.

 

[San Marzano]

The ED is dangerous because the patient had myoclonus?

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

 

[T-burglar]

I agree all of us have probably had drug errors. In residency i pushed a syringe drawn by someone else labeled" zofran and the patient brady arrested. I am 100% sure to this day that the other resident filled that syringe with neostigmine accidentally when he was drawing up his "end of case" line-up of drugs. No harm occurred in the end. I myself have accidentally put atropine in-line thinking it was calcium, a whole stick of it, and by luck i turned the syringe over in my hand and read the label before any ran into the patient, and I was able to siphon it from the line before it ran in. Another time I was wrapping up a carotid in residency and I wanted to keep the patient's blood pressure controlled during transport to the PACU - accidentally put a large dose of esmolol in-line thinking it was nicardipine and the patient's resting heart rate at the time was in the 40's. I realized this at literally the last second and grabbed the IV tubing and ripped it out of his arm before it ran in because I didn't think I even had time to try to find the roller clamp LOL. Then I placed a new IV.

 

[caligas]

 

[caligas]

“Red is almost orange. First two letters are right. I’ll go for it.”

 

[anbuitachi]

I agree all of us have probably had drug errors. In residency i pushed a syringe drawn by someone else labeled" zofran and the patient brady arrested. I am 100% sure to this day that the other resident filled that syringe with neostigmine accidentally when he was drawing up his "end of case" line-up of drugs. No harm occurred in the end. I myself have accidentally put atropine in-line thinking it was calcium, a whole stick of it, and by luck i turned the syringe over in my hand and read the label before any ran into the patient, and I was able to siphon it from the line before it ran in. Another time I was wrapping up a carotid in residency and I wanted to keep the patient's blood pressure controlled during transport to the PACU - accidentally put a large dose of esmolol in-line thinking it was nicardipine and the patient's resting heart rate at the time was in the 40's. I realized this at literally the last second and grabbed the IV tubing and ripped it out of his arm before it ran in because I didn't think I even had time to try to find the roller clamp LOL. Then I placed a new IV.

wow thats gutsy! though zofran is usually 2ml, im surprised 2ml of neostigmine caused the patient to arrest.

 

[Pinotnoirmyanmar]

Posting on a throwaway because I'm still embarrassed and shaken by my near miss last year.

In OB we were still on a shortage of hyperbaric bupi so our spinal kits didn't come with any medication in them, and we had to draw up our own .5% bupi for the spinal. My setup is usually such that I will draw up my medications into their respective syringes (bupi, fent, morphine) and then have a nurse squirt them into one of the wells of my spinal tray for me to administer. I also usually draw up other medications ahead of time as well for the case (abx, oxytocin) and put them aside. One day for reasons I still don't understand, I ended up grabbing my syringe of oxytocin instead of bupi and gave it to my nurse in preparation for the spinal. Luckily I'm pretty meticulous about labeling everything, and my nurse asked me if I was sure I wanted to give oxytocin for the spinal. As soon as I realized what happened, my heart sank because had this nurse not been vigilant, I could have easily killed a healthy 21 year old mother-to-be.

After that incident, I made some changes in my OB setup to make sure this doesn't happen again. But it really struck me how we are close to making simple yet fatal errors all the time. That nurse saved my career and the patient's life. If the patient died, I'm sure I'd be fired, sued, etc. We all know nurses who can't seem to give 2 hoots about patient care, I'm just lucky I had a nurse who was on her toes.

I keep saying that I'm assuming the patient would have died, but that's because I couldn't find anything in the literature about the effects of intrarhecal oxytocin. It's bad enough to swap IV medications, but to accidentally give a medication intrathecally, I guess that's a more unprecedented f**k up.

 

[pgg]

I realized this at literally the last second and grabbed the IV tubing and ripped it out of his arm before it ran in because I didn't think I even had time to try to find the roller clamp LOL. Then I placed a new IV.

Sounds like my near miss of the year -

I was giving a lunch break as a case was finishing up (and I'll just add this to the 7,000 reasons I hate our stupid break culture in anesthesiology). There was a pre-packaged 10 mL NS flush syringe in line on a stopcock. I used it to flush in a dose of ondansetron. As I rotate the now empty "NS flush syringe" from the stopcock I see there's a longitudinally-placed phenylephrine sticker on it. I didn't yank out the IV, just turned the stopcock and tried to suck the drug back in. It was a good IV and I got some blood back. Disconnected the line, guessed at least 500 or 600 mcg of phenylephrine actually made it into the patient, double diluted some nitroglycerin, gave 200 mcg of it about the time the HR dropped through 50. Next BP was just under 200.

 

[deleted697535]

And who the heck thinks monitoring after 2 mg of versed is mandatory?

Omg. I hope I never go to your hospital...
You wouldn't monitor someone after intravenous sedation? Wtf

 

[Psai]

wow thats gutsy! though zofran is usually 2ml, im surprised 2ml of neostigmine caused the patient to arrest.

Depends on the patient but I also doubt the story. 2mg of neostigmine just isn't that much.

 

[anbuitachi]

Sounds like my near miss of the year -

I was giving a lunch break as a case was finishing up (and I'll just add this to the 7,000 reasons I hate our stupid break culture in anesthesiology). There was a pre-packaged 10 mL NS flush syringe in line on a stopcock. I used it to flush in a dose of ondansetron. As I rotate the now empty "NS flush syringe" from the stopcock I see there's a longitudinally-placed phenylephrine sticker on it. I didn't yank out the IV, just turned the stopcock and tried to suck the drug back in. It was a good IV and I got some blood back. Disconnected the line, guessed at least 500 or 600 mcg of phenylephrine actually made it into the patient, double diluted some nitroglycerin, gave 200 mcg of it about the time the HR dropped through 50. Next BP was just under 200.

I dislike horizontal stickers! i always wrap mine around!

 

[Cryc_to_the_point]

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

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

 

[MirrorTodd]

Personally, (no judgements) I never leave syringes in line. I also would never draw up meds in a saline flush syringe. Just my personal preference.

 

[pgg]

I dislike horizontal stickers! i always wrap mine around!

So do I. I want a visual cue on every syringe no matter how it's laying. The only thing I don't like about the Codonics label printers is that they sort of have to go on lengthwise.

 

[pgg]

Depends on the patient but I also doubt the story. 2mg of neostigmine just isn't that much.

GI uses neostigmine in 1-2 mg doses to treat Ogilvie's Syndrome. The patients hate it but they don't have bradycardic arrests. I guess it's possible that the fact that they're awake and it causes pain counters the vagal effects.

 

[leaverus]

I keep saying that I'm assuming the patient would have died, but that's because I couldn't find anything in the literature about the effects of intrarhecal oxytocin. It's bad enough to swap IV medications, but to accidentally give a medication intrathecally, I guess that's a more unprecedented f**k up.

you probably would have been ok, except for a non-functional spinal but who knows. in residency I heard of another resident who pushed Pitocin through the epidural during a C-section and nothing bad happened.

I dislike horizontal stickers! i always wrap mine around!

like me, just don't make mistakes and it won't matter how the syringes are labelled.

 

[urge]

Omg. I hope I never go to your hospital...
You wouldn't monitor someone after intravenous sedation? Wtf

Wimp

 

[urge]

like me, just don't make mistakes and it won't matter how the syringes are labelled.

Google Image Result for https://i.pinimg.com/236x/26/18/5d/26185ddcf4824e913888f4e36d02387a--walking-dead-quotes-walking-dead-party.jpg

 

[T-burglar]

i can't think of anything else it could have been. The patient was waking up from anesthesia, we were all done. Whatever was in that syringe was the cause of the severe bradycardia.

 

[nimbus]

I agree all of us have probably had drug errors. In residency i pushed a syringe drawn by someone else labeled" zofran and the patient brady arrested. I am 100% sure to this day that the other resident filled that syringe with neostigmine accidentally when he was drawing up his "end of case" line-up of drugs. No harm occurred in the end. I myself have accidentally put atropine in-line thinking it was calcium, a whole stick of it, and by luck i turned the syringe over in my hand and read the label before any ran into the patient, and I was able to siphon it from the line before it ran in. Another time I was wrapping up a carotid in residency and I wanted to keep the patient's blood pressure controlled during transport to the PACU - accidentally put a large dose of esmolol in-line thinking it was nicardipine and the patient's resting heart rate at the time was in the 40's. I realized this at literally the last second and grabbed the IV tubing and ripped it out of his arm before it ran in because I didn't think I even had time to try to find the roller clamp LOL. Then I placed a new IV.

i can't think of anything else it could have been. The patient was waking up from anesthesia, we were all done. Whatever was in that syringe was the cause of the severe bradycardia.

Cardiac arrest associated with ranitidine and ondansetron combination in day care gynecologic surgery

 

[Psai]

i can't think of anything else it could have been. The patient was waking up from anesthesia, we were all done. Whatever was in that syringe was the cause of the severe bradycardia.

I've pushed neostigmine 5 mg unopposed on purpose without bradycardic arrest. The patient did need to be spruced up a bit prior to transfer from the operating table due to the parasympathetic effect on motility. If it was a 2 cc syringe and the patient was not reversed, possibly sugammadex? There are case reports of pretty significant bradycardia with that. Pediatrics case?

 

[Mr.S]

At my hospital, anyone receiving Versed is placed on a pulse oximeter and monitored, anywhere in the hospital. These nursing series of errors caused a terrifying horrific death to a human.

How about giving 2mg of versed while wheeling the patient back to the O.R.?

Does he/she have to be on a monitor?

 

[Psai]

How about giving 2mg of versed while wheeling the patient back to the O.R.?

Does he/she have to be on a monitor?

Only when you're looking back with the retrospectoscope due to a bad outcome

 

[DrZzZz]

Sounds like my near miss of the year -

I was giving a lunch break as a case was finishing up (and I'll just add this to the 7,000 reasons I hate our stupid break culture in anesthesiology). There was a pre-packaged 10 mL NS flush syringe in line on a stopcock. I used it to flush in a dose of ondansetron. As I rotate the now empty "NS flush syringe" from the stopcock I see there's a longitudinally-placed phenylephrine sticker on it. I didn't yank out the IV, just turned the stopcock and tried to suck the drug back in. It was a good IV and I got some blood back. Disconnected the line, guessed at least 500 or 600 mcg of phenylephrine actually made it into the patient, double diluted some nitroglycerin, gave 200 mcg of it about the time the HR dropped through 50. Next BP was just under 200.

Have seen a few scary drug errors in my time.

1) newer anesthesia resident treats a soft BP with a vial of phenylephrine. Nitro fixed the issue, no (acute, clear) patient harm occurred.

2) CRNA sets up an OR during Case A for the case to follow. Case A was a non-anesthesia case. CRNA leaves room set up for Case B while Case A starts. Surgical resident in for Case B gives a whole syringe of propofol (which was labeled) to this prone patient because the attending asked for Ancef and the resident thought the white stuff was just reconstituted Ancef. Anesthesia called in stat once it was realized patient was asleep. Thankfully, patient was a heavy drinker and only had a very brief apneic period. Patient was breathing and arousable by the time anesthesia got to the room. No patient harm

3) CRNA gave zofran through an epidural, thinking it was the IV. No patient harm.

4) RN on floor hooks up bupivacaine infusion meant for an adductor catheter to the IV. Only caught several hours later when anesthesia called for "increased pain scores". Luckily, the rate was low enough that the patient suffered no harm, other than a sore knee from their surgery.

It's scary the mistakes that we get away with sometimes.

 

[urge]

How about giving 2mg of versed while wheeling the patient back to the O.R.?

Does he/she have to be on a monitor?

Some of the posters in here will say it's mandatory to have a portable monitor with ekg, bp, pulse ox, and end tidal co2.

 

[MirrorTodd]

How about giving 2mg of versed while wheeling the patient back to the O.R.?

Does he/she have to be on a monitor?

Some of the posters in here will say it's mandatory to have a portable monitor with ekg, bp, pulse ox, and end tidal co2.

The thing is when we are wheeling them back to the OR after giving versed, they are monitored. They're monitored by you as you are wheeling them. You're talking to them, they're telling you what a fun ride this is, some of them are singing, if they're quiet then maybe you guess that they are sleeping, you can see the rise and fall of their chest, you can see their lips turn blue or ashen if they actually have stopped breathing long enough, plus the trip to OR from pre-op is 2 minutes max before you're telling them to move to the table. It's an entirely different situation than sending someone into a ct scanner.

 

[Robotic Wis-Hipple]

Wimp

You’re really saying a Pt on chronic PO Xanax is even remotely the same as an elderly Pt with a subdural receiving 2mg of a rapid onset sedative by non airway trained providers who then gets loaded into an obstructive imaging machine in a room alone?

Come on.

 

[Tramadeezy]

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

 

[deleted126335]

View attachment 243212 View attachment 243213

I think that this product is a step up from a safety standpoint. Getting the hospital to buy in to anything that increases costs these days is a tall order. These things do cost a little more. I am sure that anesthesia personnel make drug errors like the OP all the time. They just don't always self report and are usually able to fix a misstep without anyone being wiser.

 

[deleted162650]

Cardiac arrest associated with ranitidine and ondansetron combination in day care gynecologic surgery

Anyone else disturbed that they are doing GYN surgery at a day care??

 

[T-burglar]

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

Interesting. Makes it seem like the association between TXA and seizures is actually real.

 

[nimbus]

Anyone else disturbed that they are doing GYN surgery at a day care??

Toddlers are upping their game these days.

 

[urge]

You’re really saying a Pt on chronic PO Xanax is even remotely the same as an elderly Pt with a subdural receiving 2mg of a rapid onset sedative by non airway trained providers who then gets loaded into an obstructive imaging machine in a room alone?

Come on.

For they guy to complain about anxiety his mentation must be back to baseline.

Do you think an anxious guy goes down with 2mg of versed?

 

[Tramadeezy]

Posting on a throwaway because I'm still embarrassed and shaken by my near miss last year.

In OB we were still on a shortage of hyperbaric bupi so our spinal kits didn't come with any medication in them, and we had to draw up our own .5% bupi for the spinal. My setup is usually such that I will draw up my medications into their respective syringes (bupi, fent, morphine) and then have a nurse squirt them into one of the wells of my spinal tray for me to administer. I also usually draw up other medications ahead of time as well for the case (abx, oxytocin) and put them aside. One day for reasons I still don't understand, I ended up grabbing my syringe of oxytocin instead of bupi and gave it to my nurse in preparation for the spinal. Luckily I'm pretty meticulous about labeling everything, and my nurse asked me if I was sure I wanted to give oxytocin for the spinal. As soon as I realized what happened, my heart sank because had this nurse not been vigilant, I could have easily killed a healthy 21 year old mother-to-be.

After that incident, I made some changes in my OB setup to make sure this doesn't happen again. But it really struck me how we are close to making simple yet fatal errors all the time. That nurse saved my career and the patient's life. If the patient died, I'm sure I'd be fired, sued, etc. We all know nurses who can't seem to give 2 hoots about patient care, I'm just lucky I had a nurse who was on her toes.

I keep saying that I'm assuming the patient would have died, but that's because I couldn't find anything in the literature about the effects of intrarhecal oxytocin. It's bad enough to swap IV medications, but to accidentally give a medication intrathecally, I guess that's a more unprecedented f**k up.

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

 

[WholeLottaGame7]

Anyone else disturbed that they are doing GYN surgery at a day care??

I've seen toddlers with better hand-eye coordination than some gyn "surgeons"

 

[dannyboy1]

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

 

[Robotic Wis-Hipple]

For they guy to complain about anxiety his mentation must be back to baseline.

Do you think an anxious guy goes down with 2mg of versed?

I think the dose response curve of versed is such that neither of us can say for sure. Am I concerned about giving 2mg of versed to anyone without a pulse ox on? No. But the 5% of pts that hypoventilate from it I can manage. Clearly the same can not be said about the average floor nurse or this radiology/“sedation” nurse.

I think it’s silly to not have a pulse ox on someone you’re sedating and stuffing into a machine you can’t access if you wanted to. Double that sentiment if the person “watching” the patient can’t rescue a hypoventilating patient if they wanted to.

Rules are created for the protection of the lowest common denominator. It’s why I have to take the same standard precaution training with the housekeepers every year.

 

[dchz]

Vanderbilt didn’t tell medical examiner about deadly medication error, feds say

The first article didn't do it justice, this one is much more ridiculous.

"“Is this the med you gave (the patient?)” the second nurse asked the first nurse, showing her the baggie, according to the report. “This isn't Versed. It's vecuronium.""

"Despite the circumstances of this death, that patient’s medical records do not include any documentation of the medical examiner’s office being informed about the medication error, according to the federal investigation report."

"When questioned about this oversight by federal investigators, Vanderbilt officials said they were uncertain if the medication error had anything to do with the death at all."

Instead, it appears that a Vanderbilt doctor told the medical examiner’s office that the patient died from bleeding and that any medication errors were purely “hearsay,” according to the investigation report. This led the medical examiner’s office to decline to investigate because staff believed the patient died a natural death that was outside their investigatory jurisdiction.

Wonder if i can get the PR firm's number for down the road. These responses are great.

 

[anbuitachi]

I think the dose response curve of versed is such that neither of us can say for sure. Am I concerned about giving 2mg of versed to anyone without a pulse ox on? No. But the 5% of pts that hypoventilate from it I can manage. Clearly the same can not be said about the average floor nurse or this radiology/“sedation” nurse.

I think it’s silly to not have a pulse ox on someone you’re sedating and stuffing into a machine you can’t access if you wanted to. Double that sentiment if the person “watching” the patient can’t rescue a hypoventilating patient if they wanted to.

Rules are created for the protection of the lowest common denominator. It’s why I have to take the same standard precaution training with the housekeepers every year.

i think rules cant really cover for every scenario. but i agree rules should be created for lowest common denominator. this patient with a SAH should have had a monitor when given sedation.
with that said i dont know if anyone getting midaz should automatically need monitors. we aren't the only doctors that use benzos, a lot of people take them at home, or get them for anxiety on the floor, and on the floor the monitor is q4h.
it's just that our field as very big on safety as it probably should be.

Vanderbilt didn’t tell medical examiner about deadly medication error, feds say

The first article didn't do it justice, this one is much more ridiculous.

"“Is this the med you gave (the patient?)” the second nurse asked the first nurse, showing her the baggie, according to the report. “This isn't Versed. It's vecuronium.""

"Despite the circumstances of this death, that patient’s medical records do not include any documentation of the medical examiner’s office being informed about the medication error, according to the federal investigation report."

"When questioned about this oversight by federal investigators, Vanderbilt officials said they were uncertain if the medication error had anything to do with the death at all."

Instead, it appears that a Vanderbilt doctor told the medical examiner’s office that the patient died from bleeding and that any medication errors were purely “hearsay,” according to the investigation report. This led the medical examiner’s office to decline to investigate because staff believed the patient died a natural death that was outside their investigatory jurisdiction.

Wonder if i can get the PR firm's number for down the road. These responses are great.

I agree it's ridiculous but if you think about it, how many doctors actually know of vecuronium other than anesthesiologists and ICU doctors? Probably not many. and the person who filled out the death form is probably some intern who just started and had no idea of vec dosing. like many people said medication errors are made all the time, and most doesn't do much at all, so it's possible this doctor thought this was the case as well, instead of actively trying to hide it.

 

[Modanq]

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

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

 

[Ronin786]

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

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

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

 

[deleted162650]

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

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

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

I posted that. It happened at Emory while one of my partners was a cardiac fellow there. Surgeon actually got intubated wide awake. Otherwise it was pretty much just as you relayed it.

 

[urge]

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

It's funny how we all "know of" somebody who has made a mistake but nobody in here will ever fess up to making one.

 

[btbam]

I posted that. It happened at Emory while one of my partners was a cardiac fellow there. Surgeon actually got intubated wide awake. Otherwise it was pretty much just as you relayed it.

Correct. Surgeon is still working there.

 

[dannyboy1]

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

 

[Arch Guillotti]

An oldie but goodie.