A pharmacist here - paralytics should NEVER be in a Pyxis machine outside of the OR. I am almost obsessive about verifying the safety and appropriateness of paralytics. That very scenario has always been my nightmare.

Warning message fatigue is real. I’m an MD. We get so many insignificant warning messages that clicked through by habit. I’ve been complaining about this since the EMR took over. One cure is changing the warning messages in regards to the criticality: severe getting a red flashing screen, yellow for less severe, & white for more benign situations, etc.

I'm an ICU nurse. The last place I worked you couldn't override paralytics. They were kept in the rapid sequence intubation boxes, so none of those drugs were given without the Dr being ready to intubate. And even if she did give versed, why wasn't she monitoring the patient? Versed is for concsious sedation.

While I believe the RN in question should be held accountable for her actions, why weren't the hospital administrators who failed to report this to the state and medical examiner/coroner who said the victim died of "natural causes" (in other words, who tried to cover this up), held accountable for their actions? I don't believe the RN should be the only one taking the fall in this case.

It's so important to read the drug label when you pull from the pyxis. Even if the drug was ordered, the wrong drug could be in the bin it tells you to pull from.

Nurses please be patient with your pharmacist. There is a reason we take our time checking the orders for the entire hospital, sometimes by ourselves. We are thinking about the safety of the patients, liability of the hospital, and even the nurses’ liability in mind.

Sounds like all safety measures were bypassed. Five rights are right drug, right dose, right route, right time, right patient. ALWAYS look at your meds before giving! First semester nursing. Get back to basics.

I graduated from nursing school in 1978 and am still working. The trend is to cut nursing hours causing the nursing staff available to be rushed. If I was asked to review this incident my first audit would be how many hours had she worked the last 24 hours, how many hours had she worked the last seven days and what was her assignment that moment she made the critical error. Administrators need to stop making heros out of the nurses who work overtime at unsafe, ridiculous amount of hours. Was the nurse who made the error given a physical and drug test as soon as the error was discovered? Nurses who are working ill themselves are also congratulated instead of sent home and replaced. Expectations of nurses are becoming so unrealistically at every level. Most nurses strongly desire to do all the checks and follow ups written in the P&P but are not given the time to do so. As recently as last month my family member had her cup of medications left at the bedside and I, as a visitor was asked to be sure my relative took all her meds. Her nurse turned heel and left the room before I could even answer. I would need a WHOLE lot more data before I would condemn this nurse.

1. The hospital was undergoing a change in EMR. We all know what that is like. They were having to override everything. 2. She made a medical error and did everything right once she realized that. She reported it and took the proper steps. 3. Making this a CRIMINAL charge is a terrible precedent.4. She lost her license,which she should have, and her job

This might be one reason healthcare workers have such a high suicide rate, how can someone live with themselves if their actions lead to a patient being killed

We were taught "6 Rights of Med Admin". Right patient, right drug, right dose, right route, right time, right documentation. Fixing to take the NCLEX in a few weeks, and med admin is my greatest fear. I always assumed that this fear would go away after time. After reading this Vanderbilt story, I hope I never lose the fear, hopefully it'll prevent me from doing something regretful.

This story made me want to cry. I think this comes when we become too comfortable in our positions. There are medications we are constantly giving (such as Versed) that we believe we know like the back of our hand so we feel we don't need to check it. We get comfortable with relying on how technology will take care of us and stop using our brains. As a nursing student, I am constantly checking the six rights of medications (right patient, right route, right time, right drug, right dose, right documentation) but I know I'm being watched and under the supervision of my preceptor. I've seen nurses on the floor of my clinical not even giving a second thought and hang IVs and pass meds. What if I become that comfortable and careless? What if I made a terrible mistake like this nurse? This is a wake-up call for me to never become comfortable because that's when things get dangerous.

The overriding the pyxis to obtain the drug is not the punishable offense here, it is done in many settings such as ICU, ER. The issue was not following the 5 or 6 rights, depending where you learned, of medication administration.

Anesthetists here: She had to RECONSTITUTE the drug. Vec only comes in powder! That’s what really gets me. Also she gave all 10mLs (10mg) instead of the 2mL(2mg). That seems crazy that she didn’t realize something was amiss. Like you mentioned, I can’t imagine the hospitals practice is to give versed s monitoring. Even just 2 mg can cause someone to go apnic. Rarely but it is possible. I’m just really blown away by this. What an awful way to die.

ZDogg, your description of how frightening it must have been for this patient as she suffocated to death was so important to highlight. I am an ED RN and while you were telling this story I was focusing on how must of a cluster this would have been going down in radiology. But your description of her death really helped remind me to empathize and emphasize the gruesomeness of this error. The safety measures in place (scanning meds, second nurse check, allowing pharmacy to verify meds before they are removable from med dispensers, protocols for conscious and moderate sedation, etc) are found universally in hospitals and I'm sure even more so at this hospital. But if nursing staff refuse to subscribe or participate in these safeguards and go rogue, it's hard to mitigate patient harm. It is so easy for me to say in this forum, and I have been guilty of not scanning meds and overriding meds-- I still ache for this nurse who must be in a dark place. But this error boils down to a neglect of fundamental nursing practice and the five rights of medication administration. I mean, you have to at least look at the drug you're giving. Other sources that may have promoted this error were storing such a drug in a place where it was probably not needed, especially outside of an RSI kit; lack of knowledge about and experience with Versed and/or vec on the nurses part; the choice of Versed may have been a bit strong to take the edge of CT/MRI anxiety (I'm used to Versed being used during conscious sedation for reducing dislocation and such and even then it is done with strict protocols and monitoring the patient); and lastly nurse strain-- I'm thinking this nurse must have been in quite a rush if she was giving such a strong med as Versed to get this study over with without even glancing at the vial, and I'm really hoping she was in the weeds and not just putzing around. This really sucks...

Christ. That's nightmare material. That's going to stay with me for the rest of my career.

5 med rights 1. Right patient 2. Right medication 3. Right time 4. Right dose 5. Right route Theyve added others to it such as: right documentation, patient allergies, right reason.

Working in the emergency department we override Medication all the time. Initially hearing this medical error, I also said there is so many safety steps you missed. Like the Pyxis tells you it is a paralytic, you have to reconstitute vecuronium. However, hearing all the practices that Vanderbilt did not have in place caused the mistake. In 2018, we have a just culture that should allow for accurate reporting, so prevention can be made for future. Vanderbilt has hung her out to dry, many people here across the board missed this medication errors. She should not have prison time over this, but education should be increased. Computers need to be available, in working order, with a scanner, which is most of the time not the case. Safe staffing should be instituted across the entire United States, hospitals are cutting corners themselves by not have adequate staffing nurse ratios. It was a human error completely preventable, however process of errors happen for a reason. Maybe we should examine why hospitals are allowed to continue to under staff their facilities with zero standards? Why doesn’t someone enforce them to hold a standard of care? That is cutting corners, and Vanderbilt should be held accountable.

I have also experienced other nurses putting pressure on their peers to hurry or call them “so slow” and “can’t keep up with the pace of the ED” and it can feel like the best way to become more efficient in their eyes, is to skip the slow processes in place that are there for safety. I have felt this way at some places and I haven’t made a Med error as of yet in 11 years, but I do always look at the vial and make sure what I over ride is actually what I want since I know the machine won’t tell me. But hearing this story, I won’t do it again. It is a teaching tool, this story, and I feel like the potential for a mistake is too high. The 5 rights you can do without machines and computers.

I was taught in my orientation, "Don't cut corners when lives are at stake." That lesson really stuck with me. Even if a med error is made, the patient should have been monitored. No excuses. As a side note, I'd like to throw in how underpaid we are for the magnitude of responsibility we have.

At our institution, paralytics are only available in the pyxis in the ICUs, not step down or floor units ( unless in the induction kits). Also, when a pt goes to MRI, you can still place them on pulse ox and BP monitor. Another thing I forgot to mention, vec is not available as a push outside of the OR, only roc, and it's in the fridge (in the ICU pyxis)

Working in healthcare, especially during COVID, I completely understand how this human error could take place. At the same time, if this patient was my mother, I’d find it difficult to accept the nurse merely losing her license. Errors in medicine from medical students have decreased drastically since they have outlawed working 80 hours a week during residency and/or rotations. Sure, she could have taken the day off if she wasn’t feeling great, but as a nurse, she probably felt obligated to show up to support both her patients and her nurse coworkers who are also overworked and under appreciated.

In most instances, after a sentinal event, a review of the process is conducted, and a solution to whatever is broken in the system is found and enacted. The process was broken, and people generally aren't. There are so many things that could have been targeted in the process, rather than the nurse. And this is a scary precedent for the system.

I wanted to comment on this specifically because I am an MRI nurse at my institution. MRIs take an extremely long time depending on the particular scan and we have to medicate for claustrophobia and anxiety so much it can make your head spin. We have specific MRI safe cardiac and SPO2 monitors that we use routinely for patients that require continuous monitoring and for patients that we scan under anesthesia (with CRNA and Anesthesiologist present). If a patient is given virtually ANY medication while in the MRI suite we immediately put them on the monitor. Even if the nurse gave the med she thought she was I still can't believe the nurse didn't monitor the patient in some way. Heck even when I have orders for 0.5mg of Ativan PO (fairy dust for all the good it usually does) I still put them on the monitor. As for the med being in the pyxis I can believe some places might set up that way since MRI under anesthesia is pretty popular. We actually have separate carts for anesthesia were they keep all of their meds in that they usually get them out of but I can understand some places might not. All in all this was pretty much my nightmare scenario for my first few weeks there after coming from the floor. I just can't get past the nurse not bothering to monitor the patient. The telemetry may get messy due to interference from the scanner but the PulseOx doesn't and a plummeting SP02 would have definitely given away something was wrong.

Why did they even go straight for versed as a way to relax this patient? Why not something safer like an oral, Ativan Xanax or Valium? Anytime I have had to work with versed it required cardiac and respiratory monitoring.

As a nurse, you don't do an override nonchalantly it requires your upmost attention and seriousness, this is overwhelmingly tragic and complete fault of the nurse individual, it pains me to say that but it is so, also for her to give the drug properly the software they used should have required her to scan in the med to the pt and there are multiple stops in that process as well, I don't actually understand how this hppened, unless she completely override the med pass process and just gave the drug after pulling from accudose, either way neglectful and tragic

10 year ICU nurse, in school for my DNP, have MSN in clinical systems leadership. First, we don't know the specifics, where this med override occurred, but clearly there were mistakes made. After giving a sedative, its imperative to monitor your patient in the scanner. Secondly, overrides are necessary, especially in places such as the ICU and ED, safety falls to the RN pulling and administering the medication. The override function is necessary in case of emergent intubation, and for many other events that might happen on the floor or elsewhere. We could have a discussion about the current state of nursing, even healthcare, and the multiple implications that produced this event. Critical thinking is being removed from the nursing profession. With so many experienced people leaving due to all the ridiculous stress, lack of support from management, we are left with a workforce that is capable of task execution, and little critical thought. People are usually way to busy, relaxed, and just pain have too much going on in their work life, let alone their personal lives to give their full attention to the job. Half the time I watch new nurses and doctors on their phones throughout much of their shift. These kinds of things happen all the time. We here about it when its a major prestigious institution. Regardless, what can we do to prevent these sorts of things? From a systems view, make the override feature not suggest medications until at least 4 characters have been typed. That would have prevented this alone. Most paralytics are lit up with orange warring tape, different colored tops, etc. People become compliant, and there exists a notion of just getting through the shift for many a nurses. We as healthcare providers need to reinvent medicine, the way we practice, the way we exist as human beings. If we show such disregard and carelessness to our job, then whats the point. We can support and educate our staff better. Institutions can do much more to retain senior experienced nurses. Part of why I'm perusing a DNP is that I cannot tolerate bedside practice anymore. My critical thinking is becoming stymied. No one wants to listen, administration included. The focus on the bottom line of profit results in these kinds of actions, and the current state of our healthcare system. If we as a country, can realize human life and happiness are superior to profits, we can then start to change.

It’s a high alert drug! Why was it not two nurses that checked it before administration???

I can see this happening if the nurse normally works another unit and was floated, which already presumes that there is short staffing and added stress, that she doesn't know the physician, and is overly reluctant to "bother" the prescriber. I'll bet that the transporter team showed up without notice because they are also busy and if the patient didn't go RIGHT THEN that the scan would be shifted to an unknown time and the physician wants the results yesterday. That doesn't make it any less egregious and tragic, but I can see how the customary safeguards were bypassed.

Pharmacy tech here, nurses are always mad at the pharmacy when they can't override stuff or we aren't fast enough on verifying meds. I feel like things are just rushed these days because of how fast people want stuff.

say out loud the full name of the drug , dose and patients name while holding up the bottle and syringe before administering any drug

I work as a radiology assistant at VUMC and this isn't even the worst case we have had. A couple months ago we had a wrong side amputation on a young man. Yes as insane as this may sound with all the redundant safety measures we have things like these still happen. Please always do a through time out before any injection including contrast.

There are tons of existing safeguards to prevent errors such as this. The nurse probably needed to override the medication, acknowledge a million messages about the action of the drug, scan the medication, etc, etc, etc. The only thing I can think of is this: I work in a high-acuity neuro ICU. We are busy all of the time and rely heavily on moving quickly from one task to the next. Nowadays, with all of the built-in safety systems, tasks take longer. For instance, I override norepinephrine from the pyxis. I have to click "acknowledge" a million times. I then have to scan the medication in the med room but the bar code won't work. I try seventeen times and finally override the scan. I take the med to my patient's room. I have to sign in to scan the med but the computer won't load the interface I need. I wait. I wait longer. It finally works. I finally log in and attempt to scan the patient's ID band. Scanner won't work. Try again. Won't work. Try again. It works. I then attempt to scan the med. Error. Another error. Another error. Another error. It finally scans. Now I have to acknowledge three more warnings. The patient is receiving phenylephrine, also an alpha drug? Do you want to continue. YES, I WANT TO CONTINUE!!! FOR THE LOVE OF ALL THAT IS HOLY, JUST LET ME GIVE THE MED. Anyhow, you get the point. Due to clunky systems and care delays as a result, I have (and assume other nurses have) gotten into the habit of mindlessly overriding and clicking boxes in an attempt to not lose half an hour just trying to deliver an intervention to a patient. You've heard of alarm fatigue? Well, this is similar except for it's warning message fatigue. This doesn't in any way excuse what happened here in this exceptionally tragic case. We, as those charged with keeping the patient safe, cannot deviate from vigilance. Hopefully, transparency of the event discussion such as this will remind nurses to get back to basics, ensuring that the right drug enters the patient at the right dose every single time.

Vecuronium also is in a powder form that she had to reconstitute, another moment that should have caused a second guess.

With the frequency and inbuilt tolerance for slamming our nurses, it's a miracle this doesn't happen more.

Vec should only be limitedly available. Like RSI kits or require two nurse verification. I work in the ED where everything is an override, gotta be careful with any med changes. Would be great if MDs and others could understand how orders are done and meds pulled.

As a Transport/ Resource Nurse for my hospital, I am constantly getting pulled in million different directions. I get a lot of pushback from nurses, MDs, techs if I turn down calls and/or report to them immediately. Only RaDonda knows what made her bypass so many safety mechanisms in that moment, but there were also multiple things that helped her to fail that day. The EMS update which slows down every nursing care, no computer available in Radiology Dept, etc. It's so easy for us to say we would have never made that mistake until we do. We should have compassion and understanding for every type of med error. The Murphy's family did not want RaDonda to face jail time, but wanted to see systemic changes within the hospital to prevent these types of mistakes in the future.

Depending on the hospital and the area in which you work, particularly in ICU, as a RN you are granted access to override medications such as this. You typically do this during an emergency situation such as rapid intubation, etc. In this case the issue lies in giving the wrong medication with obviously catastrophic consequences. Clearly this wasn't an emergency situation, so why wasn't protocol followed such as right drug, right dose, right patient, etc. In some hospitals this medication is carried in a rapid intubation kit, separate from other drugs, and not in the pyxis or omnicell.

I'm a pharmacist. First of all, why didn't she try "midazolam" if "Versed" didn't work (and if she didn't know THAT generic name, she has no business in hospital nursing). Second, when I was practicing in a hospital, any paralytic that left the pharmacy was also enclosed in a baggie with a warning sticker on it. Aren't paralytics also packaged in differently-shaped containers? I do remember that succinylcholine was in a hexagonal or octagonal vial.

My 5 month old son was almost a victim of medication error in an ICU! There was a patient in the same ICU with only 1 letter difference in his and my son’s first and last name and that other patient was 18yrs old. I inquired about how they would make sure their medications didn’t get confused and asked if an alert sign could be placed on his door or bed and was told “oh, that would never happen” and that they had so many checks along the way that the possibility of that happening was close to none. The following day, I opened the drawer where his routine medication was stored and there it was...the medication for the 18yr old patient with only 1 letter difference in his name than my 5 month old son! To make matters worse, my son was on the same medication, but obviously the dosage difference for a 5 month old and an 18yr old was vastly different! I immediately confronted the nurse with what I had found and the entire ICU went into a frenzy of activity trying to figure out how the mistake had happened. I was furious! From that point on, they didn’t administer any medication to my son without me looking at it first.

And this is part of the reason I have always been very hesitant to disclose anxiety during medical stuff. I would rather grin and bear it.

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.

I’ve been on the end of this exact same circumstance, regarding the medication machine. I was in ER post-seizure, and was supposed to be started on valproic acid. I’m a pharmacist in training, and that day I had been working when I went to the hospital. Later on, the nurse gave me two large blue tablets to take. I look at them and think they look like valacylovir since I had just prepared a bunch earlier in the day. I took them and then woke up the next day and was told I had another seizure because the wrong medication was given. I should have said something to the nurse but as a patient you don’t really question those who are treating you. Anyway, what annoyed me was that my treating neurologist blamed the nurse who took the meds out, and when I called the hospital to talk about it, the ER chief told me that there is no pharmacist on duty past 5pm (what? why?) and the pharmacist who called separately blamed the nurses. Nobody really took the time to take responsibility. At least it wasn’t something more harmful but I can clearly see that they just typed in “VA” in the pixis.

Obviously so many things could be fixed here. One thing I would note, that I haven't seen mentioned much, is the use of the brand name, "Versed", rather than the generic "midazolam". In nursing school, we were taught that using the generic names of meds is the golden standard - it gives you insight into the class of med and is less likely to be confused with other medications of similar brand names. However, in real life, the brand names are easier to say and so many doctors will use these in their verbal/phone orders. For more seasoned nurses, this isn't typically a problem, but for newer nurses or for nurses new to a certain type of unit (where they aren't as familiar with the meds used regularly there) that can be really challenging to "translate" those orders correctly. It would be really helpful for everyone to get on the same page - standardizing either to the brand name or generic name, rather than the haphazard mix of things you will hear. Of course, ensuring read-backs on verbal and phone orders or doctors putting their own orders into the computer can also alleviate these troubles. Early in my career, I can recall assisting another nurse on my unit with a patient who was undergoing conscious sedation for a bedside procedure. She had received a verbal order for additional sedatives, but our policy is that the assigned nurse stays with the patient at all times once the procedure begins, so she had asked me to fetch the med "Versed". When I went into the Pyxis, I was drawing a blank on which benzo it was - all I knew was that it ended in "-am". I was tempted to just grab lorazepam. I was really embarrassed/ashamed to have to go back to the room to clarify the generic name - our Pyxis does not allow look ups of a med by brand name - because I knew they were in a rush to get the patient adequately sedated since the procedure was emergent/already underway. But I'm really glad I did go back and double check - nobody rebuked me for the delay, which was really important in establishing a positive environment for error prevention. The pressure to perform quickly and competently under stress can be really hard on nurses, especially when the scorn of doctors and other nurses can be so harsh. I think it can lead to a culture that encourages hiding one's mistakes instead of taking the time to ask the "stupid" questions just to double check or never admitting to a fault that could cause danger to a patient.

When I was in the hospital I remember the attending came in with what I believe was either residents or medical students. The attending asked someone to send an order for Ativan, but half the regular dose. Unfortunately somewhere down the line instead of getting half the dose I got DOUBLE the regular dose (4x the amount I was supposed to get). I don't remember the following 36 hours I was so out of it. Now I'm really lucky it was only ativan and not any of the other drugs I was on, but still medication errors in nonemergency settings are inexcusable.

One thing that could have been done to prevent this error was: 1st enter the order in the pt’s profile, scan the medication before giving it. That would have stopped the Rn from giving the wrong med.

This is absolutely heartbreaking. There are no words. In our facility, anytime a narcotic is pulled from the pyxis, it requires a double login. So, there are always two nurses checking what's being pulled. It isn't a perfect system and it ALWAYS hard to find and grab that second nurse (it's LTC and it's 2 nurses to 93 residents..."busy" is an understatement). But, it's at least a second pair of eyes.

That is probably hands down one of the single most horrifying ways to die. I cannot even put into words my horror. That poor girl.

ER doc here....this is a tragedy beyond measure. Should have never happened. Someone was cavalier beyond measure with their duty. Assumptions kill and will continue to do so.

These stories make me extra anxious about rotations. It’s so sad this happened.

I watched this for my Nursing Pharmacology Class and this is so mind blowing to me because every day even the smallest things as far as giving a patient water that is on a strict fluid restriction or even NPO and just double or triple checking for a moment for that patient will save their life! People of course make mistakes but we should take that extra step to make sure someone’s life is saved prior to skipping a step.

My dearest friend is a heart transplant patient. She suffered for decades, then finally needed the transplant. I can't tell you how many times she was hospitalized. She knows all her meds. The dosage, color and size of every pill. I can't tell you how many times a nurse tried to give her the WRONG meds. My friend had to verbally fight with a nurse each time, as the nurses insisted these were my friend's meds. She would calmly tell the nurse to go ask the doctor if these was in fact her meds, knowing the meds were wrong. One time the pills were actually for the patient in the next bed. Each time the wrong meds could have killed her. My friend had to be vigilant and had to become her own advocate whenever any medication was given to her. This was happening in one of the best heart hospitals in the country. It's a good thing she was conscious, mentally well, able to speak up for herself, and strong enough to not back down when someone in charge of her life insisted my friend was wrong. I can't even imagine how many people die in hospitals when the wrong meds or dosage is given, and the truth is covered up.

I'm not in the medical industry at all but it seems to me that when a dangerous drug is to be administered, the system should require another person to authorize the transaction just like in the grocery store where the cash register requires a manager override. On a side note, that sentry safe behind you if being used as a security device should be replaced with a real safe. Sentry safes offer no security at all since they can be opened with a magnet.

It was a horrible mistake, but it sounds like there weren’t any big holes in the system. By using all of two letters to get the drug name pulled up and then bypassing the system. She either was under too much pressure or over-tired but either way, that’s not an acceptable excuse in this case. Maybe we can have some sympathy for this nurse as a human being but it is not something that is excusable.

I just had a panic attack watching this video. Having been a patient myself and knowing where medical errors rank amongst the top killers in the US, my sympathies to the family.

I'm only a nursing student and don't have much "real world" experience, but my professors DRILLED into us the "Six Rights of Medication Administration" 1. Right drug 2. Right dose 3. Right patient 4. Right route 5. Right time 6. Right documentation To me it seems like this nurse skipped over these. Maybe due to exhaustion, large work load, a doctor trying to rush them, whatever. This is a terrible thing that happened but it does give us a chance to look at those safety measures that we rely so heavily on and see what needs changed. I feel so sorry for this nurse and the guilt that they are carrying, I hope they are getting the help they need.

I agree, there is a parallel in commercial aviators. As a pilot, it can be easy to get caught up in the woodwork of checklists, radio communication, alarms, managing aircraft personnel. But as the pilot you must remember to fly the plane. Fly the plane. Doesn't matter what person, protocol, or problem is gnawing your face off for attention. Fly the plane. As a senior Captain at Allegiant Air, my dad would tell me many stories of plane crashes. Every story would end with him making some reference to pilots getting caught up in this and that, but forgetting to simply keep the plane upright. It is asinine and idealistic to abolish mistakes. But you can improve systems, and that allows people to focus on doing their job. And that prevents catastrophe like this.

ICU nurse. My hospital you can override basically anything (and they should- things go 0-60 all the time). You need to scan the pt obviously and the med, draw it up, give it etc etc normal stuff. What I don't get is how did he/she DRAW up that medication without noticing? Even if they didn't have all the warning (because those suckers are COVERED in warnings) how did you not see the vials looked different? You have to look at it- we even have plastic needles to draw it up so I'm not going to stab myself and I always have to at least look at the bottle. The rest of it- not making sure your pt didn't have a bad reaction is a big, big mistake that I can see making myself/ other people making but I just can't get over not noticing the vial difference when you've overridden something or if it was a pre-filled syringe (likelihood of both looking the same?)

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.

Right patient, right drug, right route, right dose, right time, right documentation...

Absolutely horrifying...

Another note on paralytics. When you really do need to give them (not in this case). Never give a paralytic without a sedative. Sedate the patient first. That’s a living nightmare to be paralyzed without sedation!!

I’m a retired RN. We are taught until we can recite it in our sleep the 5 R’s in medication administration: The right med, the right dose, the right time, the right patient, the right route. Without fail. And to observe and document response. Without fail. Both of these WITHOUT FAIL. When I practiced many moons ago, we were required to observe with another nurse present, insulin being drawn up. Don’t know if that’s still done. Also, I’ve ticked off doctors when I worked in home health before when I’d go by their offices to pick up, say, a flu injection for the patient. The nurse would hand me a filled syringe, and I would say 🖐, I either have to draw it up myself, or watch you. I was always a little surprised when the nurses got visibly disgusted, because I know they were taught - or should have been - to do that too. We must - MUST - get to the point where we stop these mistakes.

I’m am a nurse anesthetist. This what happened is a horrible tragedy. It is always so important, especially when we feel rushed to take a breath and always double or even triple check what we are drawing up. I’ve seen students in a hurry draw up rocuronium in a syringe labeled lidocaine. Could easily happen to any of us healthcare providers If we aren’t paying extremely close attention.

Stop using brand names

6 Rights, every time. Becomes second nature when done regularly

I’ve been a nurse for 30yrs and a nurse anesthetist for 23 yrs and have practice full time my entire career. We must check the vial EVERY TIME we administer a drug. It’s one of the five rights.

I graduate from nursing school in less then two weeks making a mistake is my nightmare and keeps me up at night. Stories like this raise awareness of going back to the basics if you always do your five rights of medication there will not be a mistake. I know once you set a routine and get used to doing things its easy to ignore the 5 rights because it is time consuming but at the end of the day being safe is more important then not being behind

She must not give much versed. I wonder how much experience she has. It is so tragic. I feel for all parties involved.

Our hospital system has a scanning mechanism. We have to scan the medication and the patient bracelet. It can be overridden, but it sends up red flags in my mind when I scan and get a warning on my computer.

I’m a medical laboratory technician and for me it boils down to human error caused by the lack of common sense to double and/or triple check what is the label for anything before giving it to a patient. We are to be hyper aware of what we are doing in regards of our patients and everyone that steps through our doors including our own coworkers under massive stress. A few months ago the hospital I work for was placed in Code Green (full hospital lockdown) when a patient was brought in as a Trauma level 1. That day I was working in Transfusion Services (Blood Bank). When a Trauma level 1 is call my responsibility is to make what we call our Trauma units (4 O Neg unit of RBCs uncross matched )and container with ice and to run pack to our ED an I could not leave unless the MD either signs for the blood or verbally told units are not needed. During that call patient was brought in after being shot multiple time in their car near the park across the street from our hospital. The shooter was still loose near became an active shooter ED was in lockdown first but talking with police officers there are other ways to get in the hospital which prompted the code green. While our staff was trying to treat this patient as well as trying to move others away from doors and windows until the shooter was shot an brought in by police officers handcuffed to the bed. It was extremely stressful to all that was involved including for the other patients. Since we moved our patients out of harms way we were able to place everyone back in their rooms during all of this labels for our patients were mixed up and couple specimens were miss labeled during the confusion. Once we saw labels aren’t right during a mislabel that did a “Self Police” making sure more than one person doubled checks everything before anything was given or taken to patients an during the second check if the Staff noticed there was and issue that say hey this isn’t right or it doesn’t match. The Self Police is not used to point fingers at each other to get in trouble but it is used for times were massive stress and confusion happen to allow mistakes be fixed before anything like this case in the video happen. To insure that we are a team and hyper aware for everyone in our care.

RN/Paramedic here, I've done Rapid Sequence Intubation multiple times so I'm very familiar with both drugs. Bottom line, this nurse violated every standard of care imaginable. Besides the five rights of medication administration, how did she even know how much drug to administer without looking at the label to see her concentration of drug? Did she not know the difference between Midazolam and Vecuronium? That makes me wonder how much experience she had as an R.N., was she a new grad? Did she have training on moderate sedation? With the continued push to run at unsafe staffing levels, we have nurses taking assignments to soon without the experience necessary to take care of patients. The five rights of drug administration are to know "the right patient", "the right drug", "the right dose", "the right route", and "the right time".

Horrified. I've worked ICU nursing many years ago. I still recognize the drug name as a paralytic agent.

I don’t know all the details to feel I can talk about anyone personally but THE FIVE RIGHTS and TRIPLE CHECKS will always help. Cover your asses always, nurses. Always be safe for yourself and others ❤️

Pharmacist here. We use the powder for solution vial instead of a liquid vial. The extra reconstitution step required might have helped this error. Also, all NMB's are warning labeled at the receiving stage. So they never leave the pharmacy without additional labelling.

Came back to this page and this page seems to have common sense because Now during Covid most of the nurses are defending her saying poor work conditions in all etc. but they’re not focusing on the single-handed case of this case of incompetence

I'm an ER PA. this is a variation on a theme. People do not read. Adults think they're beyond reading. When children do it we correct them. When adults do it and they have a little bit of authority it's much harder to correct them. But still many adults do not read. How many times has someone gone to a closing on their house and not read one word of it instead asking "where do I sign?" do you really think that when someone flips to page 2 in a contract theyt actually start at the top? People actually make fun of me because I read entire documents, beginning to end. The nurse should have read. unfortunately this sentinel event requires that we institute a failsafe. The failsafe that we need is to train people to read. It's not that we need another obstacle to prescribe the medication. It's just that we can not read vital documents like they are Facebook blurbs....

This was a failure of the nurse to follow rigorous protocols in place to prevent precisely this error. As in the airline industry, check lists and protocols are developed usually as a result of something catastrophic happening, a root cause analysis being done and then recommendations being made on how to prevent it from happening again. We have the safeguards in place to prevent this from happening. Why did the nurse choose to bypass them? Is there ever a reason to bypass them? One thing we know for sure, they were bypassed and a person died a horrific death.

I'm a med student in the Philippines. Already jaded and bitter about healthcare here. I wish, so wish, that we had someone like you here. Medical issues need to be brought to people's attention and discussed by qualified people. All that happens here is social media outrage.

thanks for sharing!!!

I am a medical assisting student but I also have complex health and this makes me terrified. Both in the sense that I have to trust healthcare providers on a daily basis, but also not falling into a trap that I don’t pay attention in my working life.

When doing a conscious sedation with versed there should have at the very least had a pulse ox monitor on this patient. That would have alerted the nurse to this catastrophic error & prevented their death.

In my home country three nurses have to confirm the right medication, the right dose, the right person. If one nurse disagrees, the medication is not given and the prescriber is called to confirm, the process is then repeated before the medication is given.

Nurse anesthetist here. Most likely what happened was that the order was not checked by a pharmacist and the nurse did not want to wait for the order to be cleared. So the nurse overrode the Pyxis and chose the first drug when he/she typed “VE”. The nurse clearly didn’t look at the drug before administering it. My opinion is that paralytics should only be available in the OR, ER, and the ICU.

As a patient what I wish more health care providers would do is check in briefly when doing the 5/6 rights with me. I obviously notice they are internally checking for the policy protocols, but very rarely am I given even a brief description of what I am being given/the intended purpose. In this case the nurse should have very briefly checked in with the patient when checking the "rights" and stated the drug name and intended use/effect (even if this was discussed before the order was made). Just those 2 extra seconds would have likely saved a life. In my personal experience I was given a particular antibiotic without my consent, or any real explanation, even with the staff being aware of my history of antibiotic allergies. I was admitted for preterm labor, and I was due to be retested for GBS. Protocol dictated preventative antibiotics before a new test could be completed. I immediately started having a reaction; it was quickly handled, and a new antibiotic was given instead. It turned out I was negative for GBS, but I understand the protocol. What I wish would have been different is a brief check in with me before hanging that IV so that I would know which antibiotic I need to add to my allergy list. Even after asking I never got an answer.

I’m willing to bet understaffing was part of the equation. Bedside nursing these days is truly horrible, these hospitals stretch the nurse’s ability to SAFELY care for patients but the minute something like this happens they bring up all of their protocols that protect their organization and blames the nurse.

CVICU RN HERE. OMG!!! I felt sick to my stomach as you were telling the story of what happened to that poor soul. I can’t imagine what that poor person must have felt before they lost consciousness. Lots of people talked about overuses and rights, but I also don’t understand...versed is usually given 2mg/ml or max of 4mg for a patient breathing on their own. That’s 2ml. And we usually paralyze with the entire 10mg/10ml vial of vec. That’s a huge volume difference. Not to mention the bright yellow cap that says “PARALYZING AGENT” in all caps on the cap you have to pop off. In our MRI there is no way to scan patient and meds. Whenever I override or skip safety measures (unable to scan patient or med) huge red flags pop up in my brain and I check multiple times. I’ve seen shit happen to great nurses who are busy and stressed. I never want to hurt or kill one of my patients. I feel for the nurse who has to live with this. And for the poor patient who died in such a brutal way. I hope we can learn from this.

I'm a Registered Nurse in an ICU There are always two nurses checking drugs being administered to a patient. It can be difficult. But it's for the patients best interest. And our medication errors have decreased.

I get having paralytics in or, ed, and icus. We can override for it because we need it emergently. That said, we dual sign it and double check it with another nurse. It says paralytic all over it. Also wtf because the mg dosing for versed vs vec are huge, even the volumes are huge in difference. Like 1-2ml vs 10. We don't have a way to scan drugs in our scanners. This is a massive error in so many ways.

As an ICU nurse, there are obviously times in emergencies where you have to override medications. Unless it is an emergency, you should not be overriding medications. From what it sounds like, she was being negligent while administering the medication. Even if she was giving versed, she still should have assessed breathing and vitals. Vital signs are vital! And there's a reason why you learn the rights to medication before you are even allowed to pass medications in school!

Nursing student here, the 5 rights of medications are drilled into our heads all the time. Before we learned proper medication techniques, we learned the 5 rights of medication administration. This was a huge section of our med administration competency. I can’t imagine not doing the check of rights at least once. Right medication, dose, time, route, and patient. Where I do my clinicals, we have to check the 5 rights 3 times prior to administration, and know what the medications mechanism of action is. Its a sad event for the family of the patient, and as a healthcare professional. Like you said, it was the Swiss cheese effect.

I am a pharmacy tech at a hospital. Where I work we see safety measures overridden because of pressure to have things done in a "timely manner." We also have pyxis machines and about three years ago the ability to override and pull meds not ordered. We also have a system where you are SUPPOSE to scan the med barcode AT THE PATIENT SIDE to verify you are giving what is ordered. I know nurses dont like this bc it delays treatment, and us pharmacy techs have issues sometimes bc it slows us down refilling the pyxis.

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.

I'm not a medical professional. Perhaps the IT personnel setting up the computers used in medical facilities should remove the auto fill capabilities of computers used in the hospital. That way the name of the prescription must be completely spelled out.

I am wondering if the nurse was adequately trained to perform sedation procedures in the MRI department. I am a RN and have worked in specialty procedural areas. Currently I am a nurse Informatics specialist and part of what I do is workflow analysis and often consult with our safety specialists. Why was the order not placed then if the system was set up properly there would have been no override. What were the protocols? The pt should have been monitored during the procedure and the exam stopped if the pt showed distress. The packaging from these 2 medications look and feel different. Why was it packaged outside of a RSI box? Such a tragic story and breaks my heart. Sedation in specialty areas is high risk. We should all take a step back and look at how we are managing patients in these areas.

We need a witness when we override in our pyxis...which I had to do last night for 2 nurses and kept thinking back to this story! So preventable :/

Well said 😎

I used to be a patient of Vanderbilt and I actually left for smaller hospitals for a number of reasons. The inpatient doctors are horrible when you are a medically complex patient. I had many nurses telling me to sign out AMA and go to another hospital it was so bad, they also held me at the hospital against my will for 2 extra weeks despite my pleas. The residents and medical students also treated me like a guinea pig and when I requested they not be involved in my care they continued to see me anyway. They damaged my kidneys, let dangerous heart rhythms occur (due to not ordering my normal home medications), let me starve, let my electrolytes become completely imbalanced, etc. I am the type of patient who is very informed about my conditions and care because I have to. I constantly question doctors and asks questions and I have learned Vanderbilt doctors don't like this at all. I will never go there again. I have never felt so mistreated in my life and they completely ignored my rights as a patient. Vanderbilt is not all what people make it out to be. For acute, simple conditions they are pretty good but with other more complex issues they fall short.

This story wowed me. I am part of the rapid response team and we override medications. Its a stressful situation whenever overriding medications. Our team will do our five rights out loud so at least another member is verifying the med in the situation. That med is only in the ICUs pyxis as it is only used for ventilated patients. It also automatically flags you to pull another corresponding med as so you are not only administering a paralytic but also something to help with sedation

I also have a feeling like many others have said that this was a newer nurse and maybe even a newer doctor too. Why order versed instead of Ativan? There were many moments that she had to double check herself but didn’t. When you’re new, you have to take things slow so you can double check that the med is correct and that the dose is appropriate (especially if you have little experience with the med). This sounds so much like someone who was either rushed, didn’t have a resource readily available to consult, or was just completely ignorant. This is absolutely horrifying and heart breaking. This is so tragic for everyone involved. Everyone needs to take their time no matter what!