Patient Safety Tip
of the Week
From Tragedy to Travesty of Justice
In our December 11, 2018 Patient Safety Tip
of the Week “Another NMBA Accident” we discussed a tragic case where a patient
was administered a fatal dose of the NMBA (neuromuscular blocking agent)
vecuronium instead of the ordered Versed. We discussed a whole cascade of
errors, root causes, and contributing factors that were important in leading to
the unfortunate outcome.
At the end of that column we noted that the
nurse who administered the fatal dose had been terminated from the hospital.
While acknowledging that the nurse made several egregious errors, we noted that
there were multiple system issues that put her in position to be at the “sharp
end” of the error cascade. Now that nurse has been charged with reckless
homicide and impaired adult abuse in Tennessee (Kelman 2019).
Clearly, the nurse
who was charged made the following errors:
After entering only the
first two letters “VE” for Versed she chose the first drug shown and she
overrode a warning in a red box stating that it should be for STAT orders
She removed the vial from the ADC and did not
look at the label which was for vecuronium, not Versed.
She did not question why she had to reconstitute
this preparation (which would not ordinarily have been required if the drug was
After administering the medication to the
patient in the PET suite, she left to perform another task in the ER, and did
not monitor the patient to whom she had administered the medication. (Note that
the CMS report does not detail how long she actually observed
the patient before leaving the PET suite).
She failed to document anywhere the details of
the drug administration (again, note that there were some system issues that
contributed to failure to document).
prosecutors apparently were barred from publicly discussing the merits of the
case, a spokesman for the District Attorney’s Office said in a brief statement
that overriding the safeguards of the ADC (automated dispensing cabinet) was
central to the charge of reckless homicide (Kelman 2019b).
The nurse did
override the warning on the ADC screen. But we identified two system issues
regarding ADC overrides. First, hospital policy
and ADC settings apparently did not require an independent double check for the
even more importantly, the warning on
the ADC screen was inadequate. The nurse may well have considered this a
“STAT” order since she was told to go down to the PET suite now or they will
send the patient back here without doing the scan. A proper warning would have
said something like “Verify that the
patient is intubated and mechanically ventilated or that this drug is being
used for an intubation procedure”.
that ISMP (ISMP
2019), in its own review of
the issue following this case, agrees with us and recommends “Display an
interactive warning (e.g., “Patient must be intubated to receive this
medication”) on ADC screens that interrupts all attempts to remove a
neuromuscular blocker via a patient’s profile or on override. The warning
should require the user to enter or select the purpose of the medication
removal (“other” should not be a choice) and verify that the patient is (or
will be) manually or mechanically ventilated. This type of warning provides an
opportunity to specify why the user is being interrupted and requires the user
to document a response.”
The CMS inspection
report (CMS 2018) also does
not mention whether overriding an ADC alert was an issue unique to this nurse
or whether ADC overrides had become a routine part of the culture of the unit
(i.e. “normalization of deviance”).
We refer you back to our December 11, 2018
Patient Safety Tip of the Week “Another NMBA Accident” for discussion of all the system issues we identified as root causes or contributing factors. But,
to summarize, we can identify at least 19 points where interventions or
different decisions could have prevented this tragic death:
- Ordering the PET scan
We’ don’t know details about the patient’s condition but we’d question
whether the PET scan would have been more appropriately ordered as an
outpatient, in which case she probably would have been given an oral
sedating agent and there would have been no phone call to the Neuro ICU
for a nurse to administer an IV sedating agent.
- A good pre-PET scan checklist could have flagged
claustrophobia and the possible need for sedation before the patient was
sent to the PET suite. Then, a more informed decision about the need for
monitoring might have been made.
- Was a PET sedation protocol available?
Recognizing that a substantial number of patients require sedation for PET
scans, and that certain sedating agents are contraindicated during PET,
there should be formal protocols for PET that take into
account how long the sedation is required. Those protocols should
include specific drugs and routes of administration as well as guidelines
about who needs to be monitored and what monitoring equipment is needed.
- Choice of route of administration for a sedating agent
We wondered why an intravenous agent was chosen rather than an oral agent,
particularly since fairly long duration action
was desired here. But when we looked at practices of some PET scan units,
we found it fairly common that intravenous agents
like midazolam were used.
- A “Ticket to Ride” checklist for intrahospital transport
might, likewise, have raised the need for patient monitoring during the
- Decision that patient did not need monitoring
The decision that the patient did not need monitoring was actually made by a different nurse. The PET scan
technicians had thought the patient needed monitoring but the patient’s
nurse from the Neuro ICU told them she did not need monitoring.
- Decision to send a nurse who may not have been familiar
The nurse who was sent to administer the drug was a “help nurse” who did
not have primary responsibility for the patient. It is not clear how much,
if anything, she actually knew about that
patient. We wonder what sort of “handoff” was actually
done between the primary nurse and the nurse sent to the PET suite.
- Generic vs. brand name issue
The CMS investigative report indicates the physician order was for Versed
(brand name) but the ADC search function defaults to generic names, hence
“Versed” did not appear on the ADC search. There should be better
consistency between how brand names and generic names are handled in all
IT systems. Culture also plays a role here. We do see that, in most
settings, healthcare professionals will still call it “Versed” rather than
- ADC did not have an adequate warning
As discussed above, the ADC warning for vecuronium should have been
something like “Verify that the patient is intubated and mechanically
ventilated or that this drug is being used for an intubation procedure”.
- Double checks were not required for ADC overrides
Even though we’ve noted double checks are not
without their own problems, an independent double check might well have
identified that the wrong drug had been pulled. Note that, ideally, there
would have been two double checks (one to override the ADC warning, and
one to identify the drug that was removed from the ADC).
- Drug vial did not have salient enough warning
The vial in the current case did have a red top and message “WARNING:
PARALYZING AGENT”. Yet that was not conspicuous enough to get the
attention of the nurse. It seems to us you need to put it in some unique
sort of container, perhaps a cardboard or plastic “cage” or something that
makes it more difficult to remove as a means of attracting attention to
the high-risk nature of the medication.
- Nurse failed to look at drug name on the vial
No excuse here. This clearly would have prevented the accident.
- Nurse failed to ask herself why she needed to reconstitute
Simply thinking “I don’t recall ever having to reconstitute Versed before”
should have been a clue that this was the wrong drug.
- Nurse sent to do 2 separate tasks (ER swallow test, PET
It almost sounds like the second task was an afterthought “Since you are
going down to the ER anyway, why don’t you stop on the way and give this
sedation to the patient in the PET suite?”. We’d
certainly wonder how the communication actually took place and what
details were included in this “handoff”.
- Barcoding was not implemented in the radiology/PET suite
If there had been the opportunity to barcode scan both the patient’s ID
bracelet and the medication vial/label, it’s
likely that vecuronium would have been recognized as the wrong medication.
- Inadequate post-dose observation
The CMS investigative report does not mention how long the nurse stayed
with the patient following the administration of what she thought was
Versed. Sedation following Versed administration might take a while.
Paralysis after injection of vecuronium should be apparent within a few
minutes at most. So even observing the patient for a few minutes might
have identified the accident. What is not clear is what the patient’s
condition was when she was moved from the “injection room” to the “patient
room” where she was to stay while the radiotracer was distributed. Did no
one notice paralysis?
- No physiologic monitoring done
All thought that the medication to be administered
was Versed. Injection of Versed or other sedating agent in a patient with
an acute neurological condition should have merited monitoring with at
least EKG and pulse oximetry. Capnographic monitoring would probably have been
difficult in the PET suite. But even though an early rise in pCO2 would
have been missed, the patient ultimately would have developed hypoxia and
heart rate changes that should have led to alarms and resuscitation.
- EMAR or way to document medication administration in the
radiology/PET suite was not available.
Perhaps, if required to do formal documentation of the medication
administration at the time of administration, the nurse might have
recognized the mistake at a time when rescue of the patient was still
- Time pressures?
The previous day was a holiday and the PET unit was
very busy, likely catching up on scans that might have been done a day
earlier. If it were less pressured, perhaps the threat to send the patient
back without a scan (if she could not be sedated immediately) might not
have taken place.
It is conceivable
that a different action or decision at any one of the above 19 points might
have prevented this tragic accident. Yes, several of these relate directly and
solely to the nurse. But the majority are enabling factors that can allow a
human error to break through multiple defense systems and lead to patient harm.
In our December 11, 2018 Patient Safety Tip
of the Week “Another NMBA Accident” we concluded that it was quite conceivable
that another nurse might have made similar errors given the same set of
circumstances and contributing factors. That is, the many system issues actually put that nurse in a position where human error
would leave her at the “sharp end” of the error cascade. As such, we would not
have recommended terminating the nurse. And we think that charging this
individual with reckless homicide is an outrageous travesty of justice. This
nurse will undoubtedly live with the memory of this terrible accident the rest
of her life. But to put her through the rigors of a homicide trial, even if she
is ultimately acquitted, is simply wrong.
Some of our prior columns on neuromuscular
blocking agents (NMBA’s):
June 19, 2007 “Unintended Consequences of Technological
July 31, 2007 “Dangers of Neuromuscular Blocking Agents”
November 2007 “FMEA Related to Neuromuscular Blocking
May 20, 2008 “CPOE Unintended Consequences - Are Wrong
Patient Errors More Common?”
January 31, 2012 “Medication
Safety in the OR”
February 7, 2012 “Another
Neuromuscular Blocking Agent Incident”
October 22, 2013 “How
Safe Is Your Radiology Suite?”
December 9, 2014 “More
Trouble with NMBA’s”
December 11, 2018 “Another NMBA Accident”
January 1, 2019 “More on Automated Dispensing Cabinet (ADC)
B. Vanderbilt ex-nurse indicted on reckless homicide charge after deadly
medication swap. Nashville Tennessean 2019; Published February 4, 2019
B. Vanderbilt nurse: Safeguards were ‘overridden’ in medication error,
prosecutors say. Nashville Tennessean 2019; Published February 7, 2019
ISMP (Institute for
Safe Medication Practices). Safety Enhancements Every Hospital Must Consider in
Wake of Another Tragic Neuromuscular Blocker Event. ISMP Medication Safety
Alert! Acute Care Edition 2019; January 17, 2019
CMS (Centers for
Medicare and Medicaid Services). Statement of Deficiences.
Complaint #TN00045852. CMS 2018; Date of survey 11/08/2018
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