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Medication Error Learning

Discussion in 'EMS Talk' started by RocketMedic, Dec 3, 2018.

  1. RocketMedic

    RocketMedic King of the Improbable

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    IwAR0FcyaqcxIyduap4c8CxBmSs9I010H1cYr9ZAqjUdbz9MX1Ay8LxUGxCUM

    Short version: RN accidentally obtained and gave someone Vecuronium instead of Versed, left them unmonitored, resulting in death.

    Lessons Learned:
    1) Although the nurse is definitely to blame for the failure, they failed within the system. Everything from the availability of Vecuronium to the 5Rs to post-administrative monitoring failed here.
    2. Non-system factors: reading between the lines, the nurse was working in an ill-defined role, without adequate familiarity or training, and with an orientee. That's a significant cognitive workload, made worse by the fact that they were talking to one another during the issue and draw. Reconstitution also should have been a warning sign, but that goes to familiarity.
    3. Profound overrreliance on software.

    Your thoughts?
     
  2. akflightmedic

    akflightmedic Forum Deputy Chief

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    Link to story?
     
  3. DrParasite

    DrParasite The fire extinguisher is not just for show

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    https://www.charlotteobserver.com/news/nation-world/national/article222422170.html
    https://www.kshb.com/news/national/...wrong-drug-threatened-medicare-reimbursements

    Your lessons learned are incorrect

    1) the nurse bypassed many of the safety mechanisms and checks in place to prevent this from happening. Vec has legit uses, particularly in RSI; the system would not let her give it, so she bypassed the system and manually typed the name of the medication. She wanted versed, so this genius typed "VE" and took the first thing that come up. nurse failure not system failure.

    2) while true, at what point does personal accountability come into play? the nurse failed to monitor her patient, she failed to read the label on the medication, she had already completed training, just like everyone else, yet, she bypassed the systems instead of asking for assistance when the drug she wanted wasn't coming up.

    3) what do you mean? the software only does what it was designed to do... this was a failure on the user not to verify (which may be interpreted as a system failure, but in reality, is a user failure).

    The hospital described the situation the best: "the error occurred “because a staff member had bypassed multiple safety mechanisms that were in place to prevent such errors”"

    I see this as an individual nurse screw up, and not a system issue. If it was a system issue, I would imagine this would be a more common occurrence.
     
    MMiz, Peak, Jim37F and 3 others like this.
  4. Remi

    Remi Forum Deputy Chief Premium Member

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    Ever since I first saw this story a few days ago, I've been meaning to post it here and start a discussion. Rocket beat me to it.

    I find the topic of medication errors really interesting, and I read a lot of accounts of med errors in various safety-oriented nursing and medical sources. I think one of the reasons I find it so interesting is that something seemingly so simple can actually be so complicated. Eliminating medication errors has been a goal of patient safety groups for at least a couple decades now…..if it were easy to fix, it would be fixed by now.

    At the end of the day, a medication error always comes down to being primarily the responsibility of the person who administered the drug. But it still isn't as easy as just blaming the person who screwed up and calling it a day. There are always factors working to influence the performance of the individual giving the med, and those factors can't be ignored.

    In this particular case for instance, even though the RN massively screwed up, Vandy is hanging her out to dry in an effort to save face with CMS and the public, which is really unfair.

    There's no question at all that the nurse screwed up. I doubt anyone anywhere has suggested otherwise. That doesn't mean there weren't also system problems that, being designed differently, would have made it much less likely for this error to have happened.

    Med errors are very common. Just not usually as dramatic as this (luckily most don't cause serious patient harm, though they all have the potential to) and even when they are, they rarely make it into the national media. But don't think for a second that the chain of events that happened here was an infrequent thing, or that it couldn't happen to you under the similar circumstances.


    Overriding the patient profile in the Pyxis is not "bypassing a safety mechanism". Override is how you get meds out that haven't been entered in the profile by pharmacy. She probably got a verbal order for versed, but because versed hadn't been entered into the computer by pharmacy, she had to use override. Perfectly normal.

    Well, that's how you find things in the pyxis. Obviously she shouldn't have taken out "vecuronium" instead of "versed", but if you are in a hurry, it's easier than you think. You have "versed" on the brain and you see a drug that starts with "ve" and in your mind's eye, that "ve" is followed by "rsed", so you grab it.

    The nurse gave the patient what she thought was versed, and the patient appeared to relax and snooze, which was the expected result. The patient was having some sort of imaging done so the RN wasn't in the room. She was probably watching though a leaded glass window, but from 20 feet away someone who had just gotten 10 of vec looks pretty much exactly like you'd expect someone to look after giving them 2 of versed.

    The patient should have had pulse oximetry on after receiving versed, so if that's policy there and she ignored it, that's another hole in the swiss cheese that she owns. But if Sp02 wasn't available then you can't stick this one to the nurse.

    Failing to read the label is easy enough when you think you have the correct drug. She must have had to reconstitute the vec, and that should have raised a red flag in her mind. But these days hospitals will often have drugs in various forms, concentrations, and packaging, so seeing something other than what you are used to doesn't always get your attention they it should. And if she was unfamiliar with versed and/or vec, I can see how it could happen.

    ---------------------------------------------------------------

    So here are the things that went wrong, best as I can tell, and some ideas on what could be done to prevent them from happening again:
    • Problem: RN had to override the patient profile to get an ordered med Fix: Overrides should only be used for emergent meds. Otherwise wait for the order to go be entered and loaded by pharmacy, that way she could have chosen "versed" on the screen and only the pocket containing versed would have opened. Also: For certain (critical) medications, the entire name of the med needs to be typed into the pyxis rather than the pyxis populating the screen with meds that contain the same letters.
    • Problem: RN took the wrong med out of the pyxis, not reading the label. Also failed to read the label while preparing the med. Easy enough to do when you are in a hurry. Fix: The importance of reading labels needs to be stressed all the time. Also: Meds should have to be scanned before administration. Vandy owns that huge deficit, if they don't have that system. Also: RN's should never be pressured for time while administering meds. (good luck with that one)
    • Problem: RN reconstituted a medication that doesn't normally require reconstitution, probably due to unfamiliarity Fix: Again, reading labels and scanning.
    • Problem: Patient was not monitored after med administration Fix: Patients should be monitored closely for several minutes after receiving any IV med Also: Anyone who has received a sedating medication should be monitored with pulse oximetry, at a minimum
    As terrible as this scenario was, all this nurse really did wrong (at least, as far as I can glean from the hyperbolic media accounts) was be in a hurry, probably distracted, maybe be flustered for some reason, and lose focus and fail to read the medication label. Obviously that was a huge mistake with horrific ramifications. But the important thing to keep in mind - the learning point here - is that distractions and lack of focus happens to everyone and resulting med errors are incredibly common. This probably happens hundred of thousands of time a year in heath facilities all over. There but for the grace of god go I.
     
    Last edited: Dec 3, 2018
    Kevinf and Gurby like this.
  5. CCCSD

    CCCSD Forum Crew Member

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    From the patients point of view: EPIC FAIL.

    It’s always interesting how people will defend screw ups, then be upset that they still happen. No excuse. This was a FATAL action, which should NOT have happened.
    At least the family will get a few million...
     
  6. E tank

    E tank Caution: Paralyzing Agent

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    The problem occurred because an untrained, unqualified person was in the position she was and neither she nor Vanderbilt had the situational awareness to prevent the catastrophe.

    You see it all the time when people out of their depth take a vessel out to sea that they have no business sailing. I wouldn't call that a systems error either, because stopping something like that from happening every single time would require oppressive restraint of maritime activity.

    There is no stopping something like this happening as long as this nurse or nurses like her are practicing. And there is no way to completely guarantee against that. The one element that brought the perfect storm of the vec going to the patient's IV was the nurse's inexperience/incompetence/emotional immaturity. There is no other single element that if taken away, would have made this event different.
     
    Gurby likes this.
  7. Remi

    Remi Forum Deputy Chief Premium Member

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    Well I don't know about the nurse in question, but some estimates are that as much as 80% of nurses have made at lease one medication error, so I'm not sure how that squares with the idea that only untrained, unqualified nurses do so.
     
  8. E tank

    E tank Caution: Paralyzing Agent

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    I keep a list of mine in my bedside table. 30 years is plenty of time to make some scary mistakes. And that 80% estimate is time sensitive...it's 100% by retirement or there are nurses that don't handle medication at all.

    This kind of error is in a special category that goes far beyond a syringe swap or look a like or dosage error. Not remotely similar.
     
  9. Peak

    Peak ED/Prehospital Registered Nurse

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    I honestly can't understand the level of complacency that would have allowed for this error to happen.

    Beyond the basic tenants of medication administration there are just things that stick out to me. I have never had to reconstitute versed from a powder, and I've never had vec that has hasn't needed to be reconstituted (from a vial dose anyway, not drips from pharmacy). The wrong medication was on the screen (it's not like someone put the wrong med in the pyxis drawer, which definitely happens). The vial itself was clearly never checked for concentration, we keep at least two concentrations of versed in any critical care/anesthesia area including radiology (we have even further diluted concentrations in most pediatric care areas). Pretreatment for claustrophobia isn't an emergency, why would there be a rush? Why would you ever give a non-emergent medication that poses serious risk to a patient without the ability to monitor them, be it on a CR monitor or by direct physical exam (and I can't believe that an area in which vec is stocked in the pyxis doesn't have a CR monitor available)?

    It sounds like there were probably some serious failures on the part of the hospital system that contributed to this event, but the errors by the nurse in my opinion are unforgivable. I've seen plenty of medication errors by Paramedics, RNs, APRNs, PAs, and Docs; but this isn't even on the same scale. This wasn't a mistake, this resulted from several very serious deviations from the standard of care. This is beyond a medication error, this is criminal negligence that resulted in death.
     
  10. Remi

    Remi Forum Deputy Chief Premium Member

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    Well, I disagree and the folks who study this type of thing would as well.

    The outcome of this one was horrific but the only difference between this one and the thousands of other med errors that happen daily that get swept under the rug is bad luck. If she had taken out and given Valium or Verapamil or any of a hundred other drugs and the patient was fine, she would have been every bit as wrong but no one would have batted an eye.

    It's very tempting to chalk it all up to sheer incompetence, and clearly, the RN here is directly responsible for the outcome. But if you just leave it at that, you miss the bigger and more important point and the opportunity to learn something valuable from it.

    I once worked with a very experienced and well-respected ED nurse who was one of the lead RN's in the trauma bay of a level 1 trauma center who followed a written order for 50,000 units of heparin IVP rather than the 5,000 units SC that the order was obviously (based on the clinical situation and the fact that no one ever gets 50,000u heparin IVP) intended to direct. She had to go to two different pyxis machines - one of which was in a remote, subacute part of the ED that she rarely worked in - to get enough heparin and then draw 10 tubex's worth of SC heparin into a 10cc syringe before pushing it. Fortunately the patient was fine, in this case. This nurse could never be described as stupid or untrained or inexperienced. It happens more often than we think.
     
  11. DrParasite

    DrParasite The fire extinguisher is not just for show

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    The simple fact that thousands of medication errors occur daily should scare anyone that has ever had to have a family member admitted to a hospital....
    And she didn't question the order? She didn't go to the doctor and say "Are you sure you wanted this much this way?" The fact that she had to go to two separate machines didn't raise any flags?

    In that case, the doctor who wrote the order would probably take most of the blame, however this smart, trained, and experienced nurse should have said someone before this started pushing it. Heck, even a lowly paramedic would question the order given to them by the doc, especially if it sounded wrong.....
     
  12. medichopeful

    medichopeful NRP, ICU RN, CCRN, CEN

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    Especially in critical care areas. With the shear amount of interventions that happen on a daily basis for your average ICU or critically-ill ED patient, mistakes are going to happen. And many of them won't ever be caught, because it is simply impossible to catch every error that is made. I've made medication errors that I know about, and I'm sure I've made plenty more that I don't. The same can be said for any ICU or ED nurse, or any paramedic or healthcare provider that deals with life-threatening illnesses or injuries.

    This is a horrible story, and we can learn a lot from it. Checking the label on the medication would have been the easiest way to prevent this issue, and there's no excuse for not doing that. On a related note, I've never seen Vecuronium that has to be reconstituted at my facility, so for us to simply say "well, they should have caught it when they had to mix it" isn't necessarily fair.
     
  13. Peak

    Peak ED/Prehospital Registered Nurse

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    I definitely think that there were some systematic problems in place, don't get me wrong.

    In your friends case the major error was the dose. It sounds like it was the correct drug for the correct patient via the correct route at the correct time. It was the wrong dose and wrong concentration, and there flags that she should have caught but I get where the error occurred.

    In the vandy situation the nurse gave a high risk drug that was neither ordered nor indicated. She didn't check her med at the pyxis, she didn't check it against the order, she didn't check it before giving it, she didn't monitor the patient in a way that should be the standard of care for a patient who would have recieved IV versed. She didn't check her 5, 7, or whatever number or rights we are up to now. I agree that there are risk management steps for the future, but this nurse also ignored or overridden several safety steps in order to make this mistake and given the standard of care was negligent in several occasions. I'm all about fixing the problem and not throwing clinicians under the bus (be it medics, nursing, or medical staff), but in this case it doesn't seem like a simple mistake.

    Paramedics make plenty of medication errors, both on transfers and in the 911 system.

    I recently had a 3rd party flight crew (RN and Medic) who almost killed a infant they were bringing to us for EMU who wasn't sick because they essentially dissociated and profoundly suppressed their respiratory drive, then didn't place an airway when she lost her gag reflex and stopped breathing (they bagged her for several minutes and 'monitored' her) and tanked her pressure and gave a 10cc/KG NS bolus over 30 minutes leaving her hypotensive for most of the flight. They drilled an IO in the not sick infant because "we couldn't get a vein" (they later charted that they looked with ultrasound but didn't mention that in any part of their report; I only looked at one extremity with ultrasound and she had a well developed vasculature and I placed an IV very quickly and without difficulty), but wanted to give drugs that weren't indicated. Fortunately no long term harm occurred to the patient, although it did result in an increased level of care in hospital.

    I was charge that night; neither the sending ED doc, sending ED primary RN, sending ED charge, our PEM, PICU doc, accepting Peds doc, PICU charge, peds charge, or myself could believe what they had done or any reason for it (nor later could our EMS coordinator, peds ED medical director, CMO, our peds CNO, and the CNO of our flight program). The scary thing is that they did actually have standing orders for everything that they did and didn't do. We didn't report them to the state but we did have to have a quite lengthy discussion with their medical director.

    Not that it makes a huge difference but the paramedic was lead on that transfer, although they were both equally responsible for their actions.
     
    Last edited: Dec 4, 2018
  14. Tigger

    Tigger Dodges Pucks Community Leader

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    To me this shows the limits of "engineering controls" which are something I've tried very hard to implement at our service. Things like placing the right sized syringe with large dose vials (Ketamine comes to mind), labelling non-standard concentrations clearly, and separating look alike meds are all important. The pyxis actually does quite a bit of this for you, but it just goes to show there will always be work arounds. Identifying those "poor" work practices in a non-punitive way is super important. Perhaps more importantly is mandating that this actually happens. For me, I take a lot of crap from our senior providers for trying to develop safeguards just because "you're pushing the med, it's your responsibility to know what you're pushing." Mhhhm, no kidding. That attitude is what causes med errors, not prevents them. And it certainly doesn't promote the idea of admitting to errors so that non-punitive change can happen.

    Several years ago a neighboring service RSIed a patient using the then standard Etomdidate--Succs--tube--Vec sequence. The Vec, which was placed in the cooler to make sure no one gave it outside of an airway situation despite needing no refrigeration, was next to cardizem. Though the vials did not look particularly similar, they were of similar volume and concentration. You guessed it, the patient received 10mg of cardizem instead of vec. Some significant bradycardia occurred which was not properly treated as it was not immediately clear what had caused this. The patient ended up doing ok, but I always thought it was interesting that despite the service's best effort to ensure some sort of bizarre mis-administration of vec did not occur, harm still occurred.
     
  15. E tank

    E tank Caution: Paralyzing Agent

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    I get the point you're making. I just disagree it applies in every case. In your problem/fix post above, every one of those are standard practices/expectations yet errors persist. And they will at the hands of good and competent people.

    But I strongly disagree that we're not allowed to categorize the degree of error. In your heparin overdose account, at least the nurse knew she was giving heparin and what it was supposed to do. With @Tigger 's post, it was a straight ahead syringe swap. S**t does happen...believe me, I know.

    It's my opinion that this case is in a different category because of the number of stops the RN had to make an intentional and deliberate suspension of prudence to overcome.

    I am aware of many, many medication errors that were just near misses and never came to anything. But in nearly 35 years of caring for the sick and injured, I can't think of a more reckless disregard for a patient's well being.

    I don't know her, but I'd bet your nurse friend that overdosed the heparin would say it wasn't the same thing either.
     
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  16. DrParasite

    DrParasite The fire extinguisher is not just for show

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    I think grouping everything as a "medication error" might be part of the issue. There is a HUGE difference between a provider administering the wrong drug to a patient, a doctor ordering a provider to administer the incorrect dose of a correct drug to a patient (and no one questioning it), a provider administering the incorrect dose of the correct medication to a patient, and a provider administering the correct dose of the correct medication for a condition that wasn't indicated (but they did have standing orders for, and were treating under said orders).

    Yes, they might all fall under the umbrella of "medication error," but there are varying degrees of severity. This particular one had a lot of negative consequences, and I am pretty sure paramedics don't do this often (or if they do, they are terminated following an investigation and are told to find another profession).

    There might have been some additional system mechanisms that would have helped prevent this incident, but those mechanisms are only going to work if they are used and not overridden or bypassed.

    Mistakes WILL happen; that's a given. we are all human, and mistakes will be made. I still think this was more of a individual issue, than a systemic one. although, the more I read about the experiences of others, the more likely I am to ask to verify personally the drugs that are administered next time I or one of my loved ones end up in the hospital.
     
  17. Peak

    Peak ED/Prehospital Registered Nurse

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    I've seen plenty of wrong doses as well. Typically from titrating medications on transfers, but I've seen it from standing orders in the field and from the medics that work in EDs as well. I've probably seen a disproportionate number of medication errors from EMS since on on the receiving end of a almost entirely tertiary/quaternary referral/transfer based hospital (with the exception of what local EMS brings us) and we get really rare and unusual cases.

    That was a bit of an extreme case but far from the only one. Our local 911 EMS group loves to give a lot of versed very quickly, and I've had quite a few adult patients arrive with anesthesia induced by 10mg of IV versed given in less than 5 minutes for agitation. I've had a ton of patients who EMS wanted to pit stop in the ED due to change in status who really just needed to correctly titrate the patients pressors and sedation.

    I think the most frequent EMS medication error is in dosing saline, especially in pediatric patients. Side note, does nobody carry buretrols anymore? We had them on the bus when I was on fire, but every field crew now just seems to (incorrectly) guesstimate volume off of a one liter bag. I get that they're super old school but unless you have a pump there isn't really a safe way to dose a neo, infant, or toddler with a one liter or even 500ml bag; at least you could do push pull but nobody has an inline stopcock either.

    I'm not sure if it counts as a medication error but we got a transfer for a ostomy prolapse and the sending PA and RN couldn't figure out what a copious amount of sugar was for an ileostomy prolapse despite being requested by the patients surgeon, our PEM, and myself over multiple phone calls. I talked to the transfering crew before they picked up the patient, and that EMT and Medic also don't apparently understand the meaning of the word copious (although I think that they were deterred by the sending hospital). Turns out copious isn't one expletive packet of sugar from the coffee machine.

    I think the reason that we see so many fewer medication errors in EMS in general is that there is a much smaller number of medications on standing order in the field than can be ordered in the hospital. Because of this the EMTs, Paramedics, and RNs that work in EMS get to memorize their medications to a much larger degree.

    When I was on fire I had all of the pharmacology for all of the county medications memorized, both for peds and adults. There is no way that I could do this in the hospital, nor is it really beneficial. I memorize my emergency medications and ones I give frequently, but there are a ton of meds that I have to look up. Part of working in hospital or clinic is learning how to safely look up and give new or novel medications.
     
  18. Tigger

    Tigger Dodges Pucks Community Leader

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    We have removed burretols, they use a micro-spike and are not a good way to replace volume. As such, we have stop cocks and 20ml syringes in a "kit." Push as many syringes as the patient weighs in kilograms. This is another way we have been trying to prevent dosing errors, by having this stuff ready to go to take some pressure off the crews ahead of time.
     
  19. RocketMedic

    RocketMedic King of the Improbable

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    I heart my buritrol.
     
  20. NPO

    NPO Forum Deputy Chief

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    I worked in a job as Medication Technician in an assisted living facility prior to my EMS time. During my time there, which was short, I had several medication errors; some due to lack of proper training, but mostly due to system failures, and some probably we're my fault as well, I'm not trying to get rid of my own fault in these. The vast majority of medication errors can be presented by engineering out failure points, however, you cannot engineer out willful negligence, as is the case of this nurse.

    Modern Pyxis systems and other similar products are examples of how they have engineered out failure. You enter the patient name, you select the ordered medication, only the correct door opens, and the medication bin flashes. This is all engineering failure out of the problem.

    Human stupidity cannot be engineered.
     

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