RocketMedic
Californian, Lost in Texas
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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?
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?