December 2, 2018

News Assessment | Vecuronium, Versed & Culpability


You are probably going to dislike my opinion regarding this issue. My opinion is based solely on national news reports regarding the events. I wasn't there, I have no personal ties to the parties involved nor am I aware of their institutional practices. I'm merely a registered nurse in Florida with knowledge regarding the nursing process. This post is about the medication error only. There is more to the story but my focus is on the medication events that took place and the social media comments I've read. My opinion is based on national news accounts of the event and Vanderbilt's response.

Is the nurse to blame for the medication error?

In my professional opinion, yes. By blame, I'm implying that the nurse is responsible for the error, responsible for the incorrect medication being administered. I read the reports regarding the nurse needing to override to the drug, as it wasn't profiled to the patient due to time constraints. I'm aware that the nurse attempted to locate the drug (on the patient's medication record) in the medication dispensing system before overriding said drug. I'm aware of this, I've experienced this, and still, my opinion is unchanged.

Many people online were complaining about the override option being the problem. Do you know how many people have almost died on my floor waiting for medications to be profiled in the medication dispensing system? Many! Too many to count. Various times on my floor, we are running a code and we run out of medications on the code cart. I'm talking 40-minute codes here. We've used up all the drugs on the code cart and we MUST have the override option to save the patient's life (or attempt to anyway). The override option is crucial and necessary in the critical care setting. I don't think all floors need this option but in my opinion, this option isn't an error and it did not contribute to the nurse's actions. Apparently, the nurse typed in V-E, and instead of selecting Versed, the nurse selected Vecuronium. The nurse accepted the medication name, pulled the drug, and administered it. The order was for Versed, yet the nurse administered Vecuronium. Computers only dispense what you accept. Computers only support what you approve. Computers don't make judgment calls, they depend on you to make selections. Have I made medication errors? Yes, but I wasn't blaming a machine for my mistake. I didn't take the time to read the label and it was on me. It was my fault, I'm okay with carrying that burden every day of my life and it's a professional reminder for me to slow down each and every time I dispense a drug. I've been there. I've done that. My patient luckily had no severe complications due to my error. And even then, I'm still saying the nurse messed up. This discussion isn't about good versus evil nurses, it is about a medication error. Folks need to stop trying to extrapolate this into an assault on the entire nursing profession. It's one terrible error that a nurse made. Doctors and pharmacists make mistakes also, but this one was a nurse.

Overrides are for time-critical situations. Where I work, for a newly profiled drug to enter the medication dispensing system, it takes about 10-15 minutes. That is an enormous amount of time for a blood pressure that is 60/15 and dropping fast. The body can only compensate for so long. The patient can only wait for so long. Overrides are life-saving options for patients. Now, one could argue, is Versed an appropriate drug to be on an override list? Yes, rapid sequence intubations occur often and again, respiratory distress doesn't have 10-15 minutes to wait. It's hard to see these scenarios from the outside. But minutes matter, seconds matter. Versed is a commonly overridden drug on my floor as well. Now, should Versed be given to someone who doesn't have a definitive airway? That's is up for debate, but I've seen and administered this drug for the same reason the provider in the event ordered it (anxiety, I believe) and no one died and no harm was caused. But this patient didn't die from Versed. They died from being given a paralytic, their diaphragm stopped working, and they died a slow, agonizing death. That is the problem here. The deflection, the distractions, ignore those. Versed can be given in this situation, it was an appropriate order. Focus less on dodging and more on what resulted, who died, and whose family is forever changed. That is the tragedy here, dear God it is horrible.

I have a very long medical history, so does my husband and my son. We are forever in this hospital dealing with this, that and the other. Nursing, like all professions, has passionate, professional individuals but it also has individuals who don't care, who don't bother following protocols or proper procedures. My father was given 25 pills (his entire day's worth of medications) in one-sitting by a nurse because "they needed to catch his home medications up." He was unresponsive for two days. My father also received an inappropriate amount of insulin because "the computer told a nurse to administer this amount, so she had to do it." I can go on and on about all the subpar nursing experiences I've endured. No one EVER accepted blame. Every nurse explained why they skipped critical steps. Why they didn't do this and why this fail-safe should have stopped them because of blah-blah. It's as if they really didn't need to do the safety steps because they were told something or someone else would catch all the errors. Yeah, scary! You almost killed my family member, and I'm supposed to care about "you being super busy" or you depending on fail-safes to catch your errors without any critical thinking on your part? Do you know how much power nurses have, how easy it is for us to kill people? What was that one spiderman movie saying, with great power, comes great responsibility. I'm so over everyone giving excuses why something isn't their fault. Each and every day I'm surprised with what people can reconcile in their mind, what they can live with and what they will actively compartmentalize and block out. I've been that patient afraid because my nurse isn't focusing or listening to me. I've been that family member who comes in when their loved one is about to die because a nurse was "too busy" and an error took place. The point I'm trying to make is that there will always be distractions but certain steps must be followed. I don't know what the nurse in this story did exactly but clearly, at least one step was missed. That doesn't make him or her a terrible person, they just had a lapse in judgment. We have all been there, no one is perfect. But that doesn't mean accountability goes out the window. I have great sympathy for all parties involved. Clearly, this is a complex issue that requires a root-cause analysis. I'm well aware that I don't have every, single detail. Nor do I know every party's intentions and circumstances. But accountability isn't a zero-sum game either.

We can talk in circles about processes (drugs, pharmacy, radiology). The nurse is the point-person regarding medication administration. The nurse is physically delivering this drug. You are the final piece in the patient and medication connection. Nursing is the role you decided to take, the job you decided you wanted. Don't then back step when the shit hits the fan and tell me, "shit happens, we're only human." Great, well when your loved one is in the hospital, I hope you have that same attitude. Because usually, nurses are the BIGGEST advocates for their family members. They are often seen by the bedside making sure everything is going as expected. I know, it's hard to see the faults within ourselves and to see we can make mistakes. It's scary, but the sooner we understand this the sooner we can find out what our profession needs. We need to slow down, we need more support. We need to see that we are humans caring for humans. We make mistakes, and there is only so much technology can do. Stop dodging the errors and lean into how we can improve this process. The mediation error I had as a new nurse opened my eyes to slowing my actions down. Once that medication is in, it's in there. No amount of apologies will soothe a person who has lost a loved one. Whether I'm giving Pepcid or Propofol, my mindset of the same. Five rights and safety, take a deep breath and do it one more time for good measure. Slow things down. My job is chaotic, I live in chaos for 13 hours each shift by choice. We are professionals, getting flustered isn't an excuse for rushing a process such as this. Rushing will always end badly. I'm in code blue situations often and frequently, and my actions remain deliberate and measured. If this is what you do for a living, you should learn to work successfully and safely within the environment.

Medication errors caused by nurses don't discredit the nursing profession nor do they negate how hard we work and how we care for our communities. Don't internalize this event or get defensive. Learn something from this experience. Understand someone's life was taken and that must mean something, something must change! Understand someone died and THAT is a tragedy, and the manner was uniquely horrific. That's it. Let this event touch your heart and not simply your mind.

** Again, this is my opinion. I'm a random nurse, no one special. If you feel differently, that's cool. Please don't blow my inbox up. I'm not one for arguing online, my life is too busy for that. Oh, and don't waste your time sending rude, long messages either. I won't read them. I'm entitled to my opinion and so are you. We can be adults and disagree **