Nurse kills patient by giving vecuronium instead of versed

[Shimmy8]

Insane to have criminal charges IMO. Take her license, don’t let her be a nurse again.

Unless something comes out that this was intentional, hard for me to believe she deserves to spend time in jail.

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[Gern Blansten]

Insane to have criminal charges IMO. Take her license, don’t let her be a nurse again.

Unless something comes out that this was intentional, hard for me to believe she deserves to spend time in jail.

Agree.

 

[pgg]

Nurse was arrested this week. Article states charged with reckless homicide and patient abuse.

That is ridiculous.

 

[Psai]

Way to blame the overworked nurse and not the **** administrators that forced the conditions leading to this horrible outcome to occur.

They're always pushing for worse and worse ratios leading people to leave for greeners pastures in pracktitioner school or administration while the ones in the trenches struggle. And then all the nonsense documentation burden on top of that? 'Call bell is in reach of patient'. Absurd.

 

[pgg]

A grand jury can get talked into indicting a goldfish.

I doubt she'll get convicted. I bet using the override function on the Pyxomnidispenser is a daily occurrence there for unrelated broken system reasons, and the defense will paint a compelling picture of an overworked nurse doing what the hospital trained her to do.

Maybe (maybe) she shouldn't be a nurse any more. She definitely doesn't belong in jail.

 

[Cryc_to_the_point]

I wish nothing ill on anyone, but courts exist for things like this...

 

[woopedazz]

Maybe (maybe) she shouldn't be a nurse any more. She definitely doesn't belong in jail.

Similar could be said for some drivers that cause accidents, however they do end up in jail.
If the nurse was someone driving to work that day and got fed up sitting behind a truck --> knowingly crossed into a lane for oncoming traffic while travelling around a blind corner because it was unlikely anyone would be coming the other way/anything would go wrong --> there was oncoming traffic and that traffic had to serve to avoid the nurse --> the swerving car crashed and all occupants died --> they'd go to jail for knowingly breaking road rules and causing a fatal accident.

 

[DM27]

I finally was able to read a copy of the report. The Vecuronium was reconstituted just to clarify.

Also, criminal charges for an outlandish but not intentional or malicious error is absurd.

 

[Twiggidy]

Unfortunately it seems like this nurse is getting the Plaxico Burress treatment if anyone remembers that case. She being made an example of by the DA to send a message whether that's right or wrong. There may have been pressure from the family as well. There is a definite system problem on multiple levels that I can identify just from reading a news article. It's a shame but she made an error that resulted in death. I'm sure whatever TN definition for wreckless homicide doesn't ask "Wait, was this in a medical situation?"

This just reminds me to be careful with my drugs

 

[Mr.S]

The problem is administration types are trying to make regulations so byzantine that nobody can follow them.
Why take a low tech idea; grabbing a medication from the shelf, looking at the medication to see what it says on the bottle and administering it; and making it a technological problem of pulling up a pixis screen and waiting for the pyxis to spit out the medication. This makes the clinician lazy. No need to think about at least looking at the bottle because thats done already.

i am convinced, if it was just an unlocked kitchen cabinet and the nurse had to get versed and look at it to make sure it was versed this would have NEVER happened. And I am afraid that the solution to this incident will make us more unsafe. Now you are going to have to call not just 2 but three nurses to verify the identity of the medication and after its given all three nurses are going to have to write in the chart methods of verification.

Then a meeting will be held that the ROgue Anesthesiologists are giving medication without proper verification. So now an additional clinician will have to in the room double verifying all the medications that you give. Of course fingerprint scanners for every drawer in the OR etc etc

Keep it Low tech..

 

[Twiggidy]

The problem is administration types are trying to make regulations so byzantine that nobody can follow them.
Why take a low tech idea; grabbing a medication from the shelf, looking at the medication to see what it says on the bottle and administering it; and making it a technological problem of pulling up a pixis screen and waiting for the pyxis to spit out the medication. This makes the clinician lazy. No need to think about at least looking at the bottle because thats done already.

i am convinced, if it was just an unlocked kitchen cabinet and the nurse had to get versed and look at it to make sure it was versed this would have NEVER happened. And I am afraid that the solution to this incident will make us more unsafe. Now you are going to have to call not just 2 but three nurses to verify the identity of the medication and after its given all three nurses are going to have to write in the chart methods of verification.

Then a meeting will be held that the ROgue Anesthesiologists are giving medication without proper verification. So now an additional clinician will have to in the room double verifying all the medications that you give. Of course fingerprint scanners for every drawer in the OR etc etc

Keep it Low tech..

Disagree 100%.....Preventing medication errors is one thing where technology is very helpful. The fact that you have to enter a drug in the system before draw opens or scan it is a second check to make sure you're using the correct drug. Now of course, all systems have flaws and can use improvement. I can tell you right now, giving a nurse the ability to override a drug that has life threatening effects, without a second nurses verification for the override, was a disaster waiting to happen. Things are lenient for us in the OR because we get the benefit of being doctors but even we should probably have a second check system for some of our drugs.

I rip technology a lot but I don't think this is a situation where that take holds.

Quite honestly, the "override factor" is probably the reason she was charged. If she had say, given the wrong drug because she picked the wrong vial from a code cart it's more of a "mistake" versus picking the wrong drug and ignoring the computer telling you "hey. double check your decision"

 

[Mr.S]

Disagree 100%.....Preventing medication errors is one thing where technology is very helpful. The fact that you have to enter a drug in the system before draw opens or scan it is a second check to make sure you're using the correct drug. Now of course, all systems have flaws and can use improvement. I can tell you right now, giving a nurse the ability to override a drug that has life threatening effects, without a second nurses verification for the override, was a disaster waiting to happen. Things are lenient for us in the OR because we get the benefit of being doctors but even we should probably have a second check system for some of our drugs.

I rip technology a lot but I don't think this is a situation where that take holds.

We will disagree on this.

The nurse trusted that she had the right medication because the machine spit it out. So she didnt look at the bottle. She could not dream that the machine would spit out the wrong medicine.

The nurse was also incompetent.

BUt at least if she had to grab the medication out of the kitchen cabinet she would be forced to put her neurons to work in order to process which medication she just grabbed.. (No thats lasix put it back, thats hydralazine put it back, thats toradol put it back, versed oh ok thats it)

This situation is what happens when you protocolize everything...
Thats why some Anesthesiologist have a hard time, including myself at times. Everyone wants to make everything into an assembly line (this is how we always do it) ... but we are left holding the bag when there is a bad outcome.

Why cant you sedate this guy who cant open his mouth and has a tongue mass for a colonoscopy? (example)
Sometimes you have to think about what you are doing?
I hate protocols. I hate EMRs I hate pyxis. Why do i have to punch 10 digits in a pyxis for an OG tube?

 

[Twiggidy]

We will disagree on this.

The nurse trusted that she had the right medication because the machine spit it out. So she didnt look at the bottle. She could not dream that the machine would spit out the wrong medicine.

The nurse was also incompetent.

BUt at least if she had to grab the medication out of the kitchen cabinet she would be forced to put her neurons to work in order to process which medication she just grabbed.. (No thats lasix put it back, thats hydralazine put it back, thats toradol put it back, versed oh ok thats it)

This situation is what happens when you protocolize everything...
Thats why some Anesthesiologist have a hard time, including myself at times. Everyone wants to make everything into an assembly line (this is how we always do it) ... but we are left holding the bag when there is a bad outcome.

Why cant you sedate this guy who cant open his mouth and has a tongue mass for a colonoscopy? (example)
Sometimes you have to think about what you are doing?
I hate protocols. I hate EMRs I hate pyxis. Why do i have to punch 10 digits in a pyxis for an OG tube?

But the machine doesn't magically place Vec into itself. A pharmacist also has to place the correct drug in the correct bin. Again, it's a system issue and the technology is there to serve as a check and balance. In the very end it is human error but it doesn't excuse overriding the system in place. It's not really the same as a protocol, which I also hate. A system check is meant to make you pause and double check what you're doing. It's why nurses for many critical drugs need a second nurse to verify what they're administering.

 

[deleted171991]

I finally was able to read a copy of the report. The Vecuronium was reconstituted just to clarify.

Also, criminal charges for an outlandish but not intentional or malicious error is absurd.

Mens rea - Wikipedia

"Model Penal Code

Since its publication in 1957, the formulation of mens rea set forth in the Model Penal Code has been highly influential throughout the US in clarifying the discussion of the different modes of culpability.[12] The following levels of mens rea are found in the MPC:

• Strict liability: the actor engaged in conduct and his mental state is irrelevant. Under Model Penal Code Section 2.05, this mens rea may only be applied where the forbidden conduct is a mere violation, i.e. a civil infraction.
• Negligently: a "reasonable person" would be aware of a "substantial and unjustifiable risk" that his conduct is of a prohibited nature, will lead to a prohibited result, and/or is under prohibited attendant circumstances, and the actor was not so aware but should have been.
• Recklessly: the actor consciously disregards a "substantial and unjustifiable risk" that his conduct will lead to a prohibited result and/or is of a prohibited nature.
• Knowingly: the actor is practically certain that his conduct will lead to the result, or is aware to a high probability that his conduct is of a prohibited nature, or is aware to a high probability that the attendant circumstances exist.
• Purposefully: the actor has the "conscious object" of engaging in conduct and believes or hopes that the attendant circumstances exist.

Except for strict liability, these classes of mens rea are defined in Section 2.02(2) of the MPC."

Tennessee Involuntary Manslaughter Laws - FindLaw

"Generally, involuntary manslaughter is when a person causes the death of another human by his or her unlawful, reckless, or grossly negligent actions. It's the disregard for safety or risk of death that makes these actions criminal, rather than the intent to harm the person by the defendant. States view these accidental deaths as still criminal, but not as severe as an intentional killing.

In Tennessee, involuntary manslaughter is divided into three categories of vehicular homicide, reckless homicide, and criminally negligent homicide. These are below the intentional homicide crimes of first degree murder, second degree murder, and voluntary manslaughter (except for vehicular manslaughter which is punished at the same or higher felony level as voluntary manslaughter). Vehicular homicide is prohibited to address negligent driving, such as drunk driving or texting and driving."

She behaved negligently and recklessly. This was involuntary manslaughter. Criminally negligent homicide is a class E felony in TN: 1-6 years in prison and a fine not more than $3,000.

Sad... The American people have to make up its mind: do we want overzealous prosecuting, or do we want criminal justice reform? If the latter, we should not encourage prosecutors by electing them to juicy political positions.

 

[coffeebythelake]

The administrators and CEO of Vanderbilt should be canned for the cover up. Why aren't their names plastered over the internet?

 

[24GaugeEJ]

Paraphrasing her own words from the CMS report, she took the time to look at the packaging in order to determine how much fluid she needed to reconstitute the medication. At that point she either failed to realize she was holding a vial of vecuronium or she saw what she was holding and did not know what it was (very possible based upon ER and ICU nurses with whom I’ve worked). Sure, there was a systems failure if she was able to get her hands on this, but at some point, as an experienced nurse, she wantonly disregarded those safety measures in place to prevent incidents like this. Responsibility cannot be diffused ad infinitum.

 

[Psai]

I can tell you that I've never looked at the packaging to determine how much fluid I need to reconstitute any medication ever

 

[Twiggidy]

Paraphrasing her own words from the CMS report, she took the time to look at the packaging in order to determine how much fluid she needed to reconstitute the medication. At that point she either failed to realize she was holding a vial of vecuronium or she saw what she was holding and did not know what it was (very possible based upon ER and ICU nurses with whom I’ve worked). Sure, there was a systems failure if she was able to get her hands on this, but at some point, as an experienced nurse, she wantonly disregarded those safety measures in place to prevent incidents like this. Responsibility cannot be diffused ad infinitum.

It's all just very strange. I'm not sure how long she's been a nurse but you would think that an alarm would went off in her head when she said, "Reconstitute versed? Since when?" I really think there is more to this story and some of it will explain why a medical mistake is ending with criminal charges.

 

[coffeebythelake]

probably thought... "i got my hands on this... it can't be that bad a medication"

 

[IlDestriero]

I read the whole report about this.
In a nutshell she was some kind of floater and was asked to give midazolam to some ward patient who was already in radiology for a brain MRI or CT. She was going to the ED to sedate someone else or pick them up or whatever and went to radiology on the way. She couldn’t find the Versed in the pyxis there, knew it should be there, so overrode it and picked the first VE... drug on the list. She read the back of the label on how to reconstitute it, but not the actual drug name on the vial and mixed it in a 10cc flush syringe.
She gave it to the guy who was alone and unmonitored in the radiology waiting room and left for the ED. He was being “monitored” by the radiology tech via a camera who thought he was asleep. The tech went to get him 30 minutes later and called a code when he was unresponsive.
It’s actially even more f’ed up because when they went to try to figure out what she gave she had 3 unlabeled flush syringes in her pocket in a baggie. One was empty, one was 10ml, and one was 8 ml and, of course, the Vecuronium vial.

 

[IlDestriero]

I read the whole report about this.
In a nutshell she was some kind of floater and was asked to give midazolam to some ward patient who was already in radiology for a brain MRI or CT. She was going to the ED to sedate someone else or pick them up or whatever and went to radiology on the way. She couldn’t find the Versed in the pyxis there, knew it should be there, so overrode it and picked the first VE... drug on the list. She read the back of the label on how to reconstitute it, but not the actual drug name on the vial and mixed it in a 10cc flush syringe.
She gave it to the guy who was alone and unmonitored in the radiology waiting room and left for the ED. He was being “monitored” by the radiology tech via a camera who thought he was asleep. The tech went to get him 30 minutes later and called a code when he was unresponsive.
It’s actially even more f’ed up because when they went to try to figure out what she gave she had 3 unlabeled flush syringes in her pocket in a baggie. One was empty, one was 10ml, and one was 8 ml and, of course, the Vecuronium vial.

Perhaps if she wasted the excess at the time of removal from pyxis like she was supposed to, the guy would still be alive.
I’m not opposed to calling this clear policy violation and horror show criminal negligence.

 

[anbuitachi]

still think its a very stupid mistake and i dont think she belongs in jail. like others said we've all made mistakes. add in some bad luck and may cause serious morbidity. i wonder how many years she'll be in jail for

 

[Aether2000]

Several pain physicians have been charged and tried for murder and manslaughter over prescribing of opioids resulting in death. Some have been convicted. The nurse being charged is consistent with current jurisprudence.

 

[chocomorsel]

Perhaps if she wasted the excess at the time of removal from pyxis like she was supposed to, the guy would still be alive.
I’m not opposed to calling this clear policy violation and horror show criminal negligence.

That would require an extra nurse. And who the heck has time to be hunting down an extra nurse?
Ain't nobody got time for that!!!!

It is odd though to give a drug in a waiting area. I have had an CT and they didn't get my IV in till I was in the actual CT room. Giving patients in waiting areas drugs seems like it could totally go haywire.

 

[chocomorsel]

Several pain physicians have been charged and tried for murder and manslaughter over prescribing of opioids resulting in death. Some have been convicted. The nurse being charged is consistent with current jurisprudence.

From what I have read, the pain docs or pill mill who've been charged, have been charge with prescribing obscene amounts of narcotics to patients. Are there some who've been charged who've prescribed normal or small amounts of narcotics to patients?

 

[Mr.S]

Disagree 100%.....Preventing medication errors is one thing where technology is very helpful. The fact that you have to enter a drug in the system before draw opens or scan it is a second check to make sure you're using the correct drug. Now of course, all systems have flaws and can use improvement. I can tell you right now, giving a nurse the ability to override a drug that has life threatening effects, without a second nurses verification for the override, was a disaster waiting to happen. Things are lenient for us in the OR because we get the benefit of being doctors but even we should probably have a second check system for some of our drugs.

I rip technology a lot but I don't think this is a situation where that take holds.

Quite honestly, the "override factor" is probably the reason she was charged. If she had say, given the wrong drug because she picked the wrong vial from a code cart it's more of a "mistake" versus picking the wrong drug and ignoring the computer telling you "hey. double check your decision"

dude i overide stuff all the time. I cannot be bothered with the pyxis machine slowing me down. It wants too much info. I am a busy man. It wants me to do clerical work too. it wants me to count how many vials are in the drawer after every time. All i care about is that there is a bottle in there. thats it.
I purposefully miscount to say therare zero bottles of diprivan..
Now the pharmacist gets that alert. and comes a runnin'! and finds 21 bottles! and looks at me. I just shrug my shoulders and point at the circulator

 

[Aether2000]

Most pain physicians were charged because of overprescribing, but that is a relative term, and some patients still receive massive doses of morphine equivalents, especially when pain physicians prescribe methadone, and do not recognize the non-linearity of dosing with MED. Many were prescribing what were later determined to be dangerous combinations of opioids, but most were charged for prescribing from 5-10 years previously, even though the standards of care were quite different in 2009 vs. 2019.

 

[lakersbaby]

I'm going to have to dissent with most of yall on this. This nurse was beyong negligent. She had probably 4-5 chances to look at the vial (getting from pyxis, reconstituting with saline, shaking it up, drawing the contents etc..). Patient died a horrific death and there has to be some form of justice for her not just a nurse losing her license. Each catastrophic mistake could be seen on a case to case basis and not some broad rules where some people should never be prosecuted for a mistake just because they are in healthcare.

 

[Consigliere]

Ain't nobody got time for that!!!!

Daaaaaamn Sweet Brown! Nice of you to stop by SDN. You must have recovered from that case of bronchitis.

 

[chocomorsel]

Daaaaaamn Sweet Brown! Nice of you to stop by SDN. You must have recovered from that case of bronchitis.

You know I did!!!
Thank you honey for asking.