Medication Error Learning

[FiremanMike]

I have a different and rather unpopular opinion on whether medical errors can be considered criminal or not.

To start, there are numerous crimes where intent can be defined as reckless or negligent behavior that resulted in injury or death. This doesn't mean you purposely killed someone, but that your actions were so egregious that the actions directly caused harm/death.

I'm not a lawyer, so I don't know how to truly compare recklessness vs negligence in this case (as it applies to criminal intent), but this case laid out all those facts and a jury of her peers agreed with criminal negligence.

Here's the meat of this case
1. She's an experienced neuro ICU nurse, I could maybe get behind a new grad nurse not immediately recognizing a problem.
2. Drawing vec requires several steps to reconstitute and administer.. Any reasonable provider should have had alarm bells clanging in their brain that something isn't right here.
3. I've given vec, several times. The patient completely stops moving and breathing in under a minute. The only way for this to have gone unnoticed is for her to have slammed the vec and then flown out of the room without reassessing. Hell even versed kicks in pretty quick, so if they were giving this to reduce agitation, she should have already planned on sticking around to ensure the desired effect occurred. If she had stayed a minute to evaluate the drug she gave, she would have identified the apnea, BVM'd the patient until they could be intubated until the vec wore off, and this whole thing has a happier ending.
4. Blaming the pyxis override function is a cop-out. If I'm looking for versed, can't find it, type in VE, and then just randomly pull the first vial of anything that starts with VE and assume that's it, that would be pretty damned reckless. Is it really too much to ask to take an extra .25 seconds to read the entire label.
5. Blaming the lack of patient scanner is another cop-out. If my patient/med scanner is down, that's clue #2 that I need to be more diligent in double checking the MAR and the vial I have in my hand.

She made several huge mistakes that resulted in a patient death. She ignored everything she learned in nursing school and quite a few things she learned along the way in the ICU, and because of a series of mistakes and incompetence, someone died.

And now everyone is jumping on the "just culture" and "no one will report" bandwagon. Listen folks - there is a line in which reporting it through the proper channels just isn't enough. I can't stab a patient in the face and then be absolved of responsibility just because I told the charge nurse I did it. I appreciate that she reported it and owned her mistake and I admire her integrity, but we wouldn't allow a drunk driver off the hook after smashing into grandma just because he said "I admit I was drinking and driving, I'm very sorry and I take responsibility".

TL : DR - her ****-ups and incompetence were so epic in this case that her actions were considered criminal negligence and a jury convicted her of such. Anyone who looks at what happened and think "oh jeez this could happen to me" needs to seriously look in the mirror. If that's true, it's time to change your approach to patient care or get the **** out.

 

[Carlos Danger]

This should probably be kept in the domain of licensure and civil damages.

However, I do find many in the healthcare community are trying to shift all blame onto the “system”. I find that a very troubling trend; where is the personal accountability and responsibility? People keep saying this is a “systemic failure”; I don’t think it is. Multiple safeguards were bypassed, for one reason or another. Aside from what should be routine manual validation of drug and dose, the Pyxis was overridden and the medication wasn’t scanned at any point. Either of these systemic safeguards could have prevented this tragedy. Additional institutional controls don’t work when individuals categorically ignore them, as happens routinely both in this case and in ERs everywhere. No one has explained to me how n+2 safeguards would’ve prevented this, when people already find n safeguards cumbersome, time-consuming, and not worth following.

The true “systemic” change needs to be a culture change, of following the existing safeguards every time. And I think it needs to be driven by the individual.

The reality is, we DO count on engineering controls for patient safety, and when they work the way they are designed, they generally do add a significant layer of safety. They aren't meant to replace accountability and personal responsibility, but rather to hopefully offset the fact that the stress and distractions and multitasking that is a near constant on any busy nursing unit creates a perfect storm for fostering mistakes of all types. This is well-studied and well understood. We can say "just pay attention" all we want, but humans will always occasionally screw up. It isn't incompetence, and I don't think it can even fairly be called negligence. It is just part of the way that humans perform in busy, stressful situations.

As for safeguards.....an override is not a safeguard - it is literally just another softkey that needs to be pushed, and needing to do so is so common that it is totally meaningless. This is not much different than the well studied phenomenon of "alarm fatigue" wherein staff members don't notice clinical alarms because they go off so constantly. Also, the scanner in this area was reportedly not working, and even if it were, it would not have necessarily prevented her from continuing. So you can't really say that n+2 safeguards were ignored, because any safeguard that can be easily ignored is not a safeguard at all.

There are some things that likely would have prevented this. First, vecuronium should not have even been available from a Pyxis in a radiology suite, even with an override - that alone is pretty inexplicable. That's like storing concentrated 100ml bags of Kcl next to your 100ml bags of NS in your med bag on the ambulance. Second, the reason she hit override in the first place was because midazolam reportedly didn't appear in the available list when she typed in "ve" for versed; if it had been displayed she would have selected it and there would be nothing else to the story. Also, sedating drugs in such a setting should require verification by two RN's, similar to the way that insulin and anticoagulants and electrolytes often do. Lastly, any patient receiving any sedating drug should have been monitored with pulse oximetry at a minimum - that last line of defense would quite possibly have saved the patient's life, even after the error occurred.

Anyone who looks at what happened and think "oh jeez this could happen to me" needs to seriously look in the mirror. If that's true, it's time to change your approach to patient care or get the **** out.

Sorry man, but you could not be more wrong about this. I assure you that being confident that something like this could never happen to you is a much bigger danger than admitting that you could potentially make a similar mistake. Nevermind that this attitude is the exact opposite of the Just Culture approach.

The thing that needs to be understood is that medication errors are extremely common - much more so than most people realize. Some estimates are that 1.5 million patients are harmed by medication errors each year; fortunately the large majority of this harm is not considered serious. Consider that for every error that is known to cause patient harm, several others are likely committed and never discovered, or at least not reported. They wouldn't be as common as they are if they only happened to reckless or incompetent nurses.

Perhaps you will never make a medication error. But even if you don't personally, I promise you that it will be very early in your nursing career before you see one committed by an otherwise very good nurse who you would never say should "get the **** out". Then, you'll eventually see another. And perhaps another still. And then you'll realize that those were just the ones that you were aware of. At some point, you WILL have at least one close call yourself. Before long, you'll realize that it COULD happen to you, and even if you don't think you have ever made such an error, you will start wondering to yourself if maybe you have and just didn't realize it.

 

[FiremanMike]

The reality is, we DO count on engineering controls for patient safety, and when they work the way they are designed, they generally do add a significant layer of safety. They aren't meant to replace accountability and personal responsibility, but rather to hopefully offset the fact that the stress and distractions and multitasking that is a near constant on any busy nursing unit creates a perfect storm for fostering mistakes of all types. This is well-studied and well understood. We can say "just pay attention" all we want, but humans will always occasionally screw up. It isn't incompetence, and I don't think it can even fairly be called negligence. It is just part of the way that humans perform in busy, stressful situations.

As for safeguards.....an override is not a safeguard - it is literally just another softkey that needs to be pushed, and needing to do so is so common that it is totally meaningless. This is not much different than the well studied phenomenon of "alarm fatigue" wherein staff members don't notice clinical alarms because they go off so constantly. Also, the scanner in this area was reportedly not working, and even if it were, it would not have necessarily prevented her from continuing. So you can't really say that n+2 safeguards were ignored, because any safeguard that can be easily ignored is not a safeguard at all.

There are some things that likely would have prevented this. First, vecuronium should not have even been available from a Pyxis in a radiology suite, even with an override - that alone is pretty inexplicable. That's like storing concentrated 100ml bags of Kcl next to your 100ml bags of NS in your med bag on the ambulance. Second, the reason she hit override in the first place was because midazolam reportedly didn't appear in the available list when she typed in "ve" for versed; if it had been displayed she would have selected it and there would be nothing else to the story. Also, sedating drugs in such a setting should require verification by two RN's, similar to the way that insulin and anticoagulants and electrolytes often do. Lastly, any patient receiving any sedating drug should have been monitored with pulse oximetry at a minimum - that last line of defense would quite possibly have saved the patient's life, even after the error occurred.


Sorry man, but you could not be more wrong about this. I assure you that being confident that something like this could never happen to you is a much bigger danger than admitting that you could potentially make a similar mistake. Nevermind that this attitude is the exact opposite of the Just Culture approach.

The thing that needs to be understood is that medication errors are extremely common - much more so than most people realize. Some estimates are that 1.5 million patients are harmed by medication errors each year; fortunately the large majority of this harm is not considered serious. Consider that for every error that is known to cause patient harm, several others are likely committed and never discovered, or at least not reported. They wouldn't be as common as they are if they only happened to reckless or incompetent nurses.

Perhaps you will never make a medication error. But even if you don't personally, I promise you that it will be very early in your nursing career before you see one committed by an otherwise very good nurse who you would never say should "get the **** out". Then, you'll eventually see another. And perhaps another still. And then you'll realize that those were just the ones that you were aware of. At some point, you WILL have at least one close call yourself. Before long, you'll realize that it COULD happen to you, and even if you don't think you have ever made such an error, you will start wondering to yourself if maybe you have and just didn't realize it.

Yes the safeguards that should have fixed her failed, but when the safeguards fail, one can choose to become more or less diligent, she chose the latter. When Pyxis opens the door and I have to grab fluid from all the choices there, I always double check that I have the right one.

Again I refuse to acknowledge this as a minor med error. Let’s stipulate she’d never seen vec before so it didn’t immediately stand out that vec is a powder that gets reconstituted. She has definitely never seen versed as a powder so that alone should have been a moment for pause. She presumably didn’t double check the concentration to check that she was giving the correct dose in the MAR, if she had this would have been yet another opportunity to notice she wasn’t giving the right medication. Lastly, she didn’t reassess her patient after giving what she thought was versed to calm an agitated patient for MRI to ensure the desired effect. Both IV versed and IV vec have a rapid onset and had she stuck around for even a few minutes she would have noticed apnea and corrected that issue.

She was undeniably set up for failure by Vanderbilt, but at the same point she didn’t just miss/ignore a single red flag as is the case in the overwhelming majority of med errors (yes I have made them and will possibly make again), this was a series of ignoring several red flags and failing to assess her patient to identify life threatening issues.

 

[MonkeyArrow]

The reality is, we DO count on engineering controls for patient safety, and when they work the way they are designed, they generally do add a significant layer of safety. They aren't meant to replace accountability and personal responsibility, but rather to hopefully offset the fact that the stress and distractions and multitasking that is a near constant on any busy nursing unit creates a perfect storm for fostering mistakes of all types. This is well-studied and well understood. We can say "just pay attention" all we want, but humans will always occasionally screw up. It isn't incompetence, and I don't think it can even fairly be called negligence. It is just part of the way that humans perform in busy, stressful situations.

I agree. However, for the engineering controls to work as designed, they must not be intentionally ignored. I would be a lot more sympathetic if this were an emergent situation, with verbal orders and a time-sensitive need for the medication. This was not.

As for safeguards.....an override is not a safeguard - it is literally just another softkey that needs to be pushed, and needing to do so is so common that it is totally meaningless. This is not much different than the well studied phenomenon of "alarm fatigue" wherein staff members don't notice clinical alarms because they go off so constantly. Also, the scanner in this area was reportedly not working, and even if it were, it would not have necessarily prevented her from continuing. So you can't really say that n+2 safeguards were ignored, because any safeguard that can be easily ignored is not a safeguard at all.

A couple of things here. The override is circumventing a safeguard, which is not being able to pull a medication that is not ordered and verified. I agree that overriding is more common than it should be; however, that is in many cases an individual decision. It is faster/more convenient/easier to override than to call pharmacy/take the extra step and not override the med. That works fine, until it doesn't.

I agree with with your statement, as very specifically worded, that a working scanner would not have necessarily prevented her from continuing. However, a working scanner, even if she attempted to do it after the fact, would have signaled a fault when she scanned the vial of vec and a patient's wristband that didn't have an order for such. The medication error would have still happened, but prompt recognition would have (should have) allowed for immediate airway management. An uncomfortable, tortuous situation for the patient, but one that would prevent a hypoxic cardiac arrest and resulting anoxic brain injury.

I think you misunderstood my n and n+2 comment. I'm saying that there were n safeguards already in place at the time of this incident. If the blame falls on the system and more safeguards are to be implemented in the future (n+2), what makes you think that those extra safeguards will also not be similarly ignored?

The issue with an impenetrable safeguard is what happens in a true emergency situation-- exactly what the override button was built to stand for. It gets abused currently; why wouldn't a future iteration get similarly abused? Similarly, we can think of hypothetical safeguards that are more fail-safe. However, that must be balanced with practicality. You can't have a failsafe that takes an hour to go through the process of, as that is not practical for patient care. Engineering controls are meant to augment human judgment, not replace it entirely. So there must be some balance between safety and accessibility, otherwise we're right back where we started. It takes too long to pull a med the "right" way, so people circumvent the system.

Additionally, what I was trying to express in my previous post is that there needs to be a cultural shift at the level of the individual. It is considered acceptable to override med cabinets because everyone does it. I can assure you that our administration's official policy is much more stringent than current practices, the clipboards track and audit med compliance (both overrides and scanning), and nurses' end of year performance reviews and raises are staked on these metrics. But bypassing these safeguards occurs regularly. This culture gets perpetuated down, to new grads during their "residency" and to new hires during orientation and nothing changes. Individuals need to start following the safeguards, and once a critical mass of individual nurses on a given unit do this, it will be considered taboo not to. Admin can email and make new policies all they want, but true change comes at the level of the individual nurse.

There are some things that likely would have prevented this. First, vecuronium should not have even been available from a Pyxis in a radiology suite, even with an override - that alone is pretty inexplicable. That's like storing concentrated 100ml bags of Kcl next to your 100ml bags of NS in your med bag on the ambulance. Second, the reason she hit override in the first place was because midazolam reportedly didn't appear in the available list when she typed in "ve" for versed; if it had been displayed she would have selected it and there would be nothing else to the story. Also, sedating drugs in such a setting should require verification by two RN's, similar to the way that insulin and anticoagulants and electrolytes often do. Lastly, any patient receiving any sedating drug should have been monitored with pulse oximetry at a minimum - that last line of defense would quite possibly have saved the patient's life, even after the error occurred.

The Vec was pulled from the NICU accudose, not the radiology one (per CMS report, page 7, https://www.documentcloud.org/documents/5346023-CMS-Report).

Correct, midazolam did not appear because the Pyxis only had generic names programmed and not brand names. This was (likely) done to reduce the number of look-alike/sound-alike names. This situation is tough. You add the generics only to reduce the number of potentially similar sounding names (i.e. Vecuronium and Versed both would have popped up if you programmed the Pyxis for both brand and generics after typing in "ve", so it is just as easy to see how a med error could happen there too if both were options and you weren't paying attention which one you clicked on.). However, not having the brand name when it is commonly used can also lead to errors when you go looking for something that isn't there, as happened here. I will say this nurse should have known this, routinely pulling Versed in this system for multiple years, but I digress.

Two-nurse verification is probably an appropriate next step. However, I have seen this circumvented just as many times as I have seen the Pyxis overriden. For example, the second nurse will only look at the amount drawn up in the syringe, and not the vial it came from. Or, more egregiously, the second nurse, especially in cases where there is close relationship with the primary nurse or where the primary nurse is considered "strong" or "a good nurse" (i.e. implicitly, that they wouldn't make a med error), won't even look at the syringe and just type in their credentials.

Pulse ox should have been used. That's why radiology needed an RN to come down and administer it. They do not have the ability to appropriately monitor the patient after. I'm pretty sure that Vandy has that rule somewhere written down, but again, it wasn't followed here.

 

[Carlos Danger]

The issue with an impenetrable safeguard is what happens in a true emergency situation-- exactly what the override button was built to stand for. It gets abused currently; why wouldn't a future iteration get similarly abused? Similarly, we can think of hypothetical safeguards that are more fail-safe. However, that must be balanced with practicality. You can't have a failsafe that takes an hour to go through the process of, as that is not practical for patient care. Engineering controls are meant to augment human judgment, not replace it entirely. So there must be some balance between safety and accessibility, otherwise we're right back where we started. It takes too long to pull a med the "right" way, so people circumvent the system.

Two-nurse verification is probably an appropriate next step. However, I have seen this circumvented just as many times as I have seen the Pyxis overriden. For example, the second nurse will only look at the amount drawn up in the syringe, and not the vial it came from. Or, more egregiously, the second nurse, especially in cases where there is close relationship with the primary nurse or where the primary nurse is considered "strong" or "a good nurse" (i.e. implicitly, that they wouldn't make a med error), won't even look at the syringe and just type in their credentials.

Probably the most reliable process / engineering solution to the problem of nurses withdrawing the wrong drug is pretty simple, and would likely have prevented this: First, high risk drugs (insulins, heparins, concentrated electrolytes, NMB's, etc) require a second log-in to dispense. Second, an absolute hard lock on these drugs being dispensed without an order being entered by a provider and review by a pharmacist. The combination of these is probably as close to fool proof as you can get.

As for accessibility, these drugs are rarely needed quickly. If that is a real concern, an emergency kit can be stocked that can only be accessed by hitting the "EMERGENCY KIT" soft key (no drug names present in the description) and then by breaking the plastic seals that hold the box closed.

 

[Carlos Danger]

The overall point is that by multiple accounts, there were many issues with the systems and culture at Vanderbilt that contributed to the likelihood of something like this happening. These things don't happen in a vacuum, or at least, they are much less likely to happen when systems are working as they should and when nurses aren't overwhelmed with workload and distractions. The truth is, at a place the size of Vandy, and especially with the culture and problems that apparently were in place at the time this happened, errors were probably much more common than anyone is comfortable contemplating. Fortunately, they rarely have such severe consequences as this one, so they largely unnoticed and ignored.

The facts that the environment probably contributed heavily to this happening and that medication errors occur much more frequently than is commonly realized don't begin to absolve this individual of responsibility, of course, and nothing that I've ever said on the issue is meant to indicate that I think they should. But, while it might make people feel better about taking the "just burn the witch at the stake!!" position and then burying their head in the sand about all the relevant factors, that isn't a fruitful approach to preventing this type of thing.

Frankly, I am not really interested in the bad decisions made by this individual, because bad choices by humans are a given. It is easy to look at a chain of poor decisions and ask "what in the world were you thinking?" and while that needs to be done, focusing too much on that misses the bigger picture. We know that even smart, well trained, conscientious people will occasionally make mistakes, especially when they are tired, stressed, overworked, distracted, or in an environment that is novel to them. This is a well described, well-known, widely accepted fact that must be accounted for and compensated for to every degree that is practical. Anyone who thinks that we can scare the human nature out of people by threatening them with a felony record and possibly prison time is ignoring reality and doubling down on an approach that has failed repeatedly.

 

[FiremanMike]

Frankly, I am not really interested in the bad decisions made by this individual, because bad choices by humans are a given. It is easy to look at a chain of poor decisions and ask "what in the world were you thinking?" and while that needs to be done, focusing too much on that misses the bigger picture. We know that even smart, well trained, conscientious people will occasionally make mistakes, especially when they are tired, stressed, overworked, distracted, or in an environment that is novel to them. This is a well described, well-known, widely accepted fact that must be accounted for and compensated for to every degree that is practical. Anyone who thinks that we can scare the human nature out of people by threatening them with a felony record and possibly prison time is ignoring reality and doubling down on an approach that has failed repeatedly.

But don't you agree that at some point, the totality of bad decisions and poor judgement rises to the level of reckless behavior, and that reasonable person should anticipate that these actions could lead to serious harm or death?

She essentially pulled a random drug out of the drawer, slammed it, then walked away, and that was only one of several errors she made.

Nurses/medics/docs are given an immense responsibility and the tools do to good but can also cause harm. We have a responsibility for our knowledge and actions. There has to be a line somewhere in the sand that, when crossed, is just too egregious to handle with a slap on the wrist.

 

[DrParasite]

She essentially pulled a random drug out of the drawer, slammed it, then walked away, and that was only one of several errors she made.

See, this is why I like @FiremanMike... straight to the point, and factually accurate... are you sure you aren't from NJ?

Nurses/medics/docs are given an immense responsibility and the tools do to good but can also cause harm. We have a responsibility for our knowledge and actions. There has to be a line somewhere in the sand that, when crossed, is just too egregious to handle with a slap on the wrist.

This nurse made some pretty egregious mistakes. However, Vanderbilt doesn't get a pass because of her massive screwups. There are systemic issues that need to be addressed (some that appear to have already been done), and hopefully changes will occur that can prevent this from happening in the future.

She was undeniably set up for failure by Vanderbilt, but at the same point she didn’t just miss/ignore a single red flag as is the case in the overwhelming majority of med errors (yes I have made them and will possibly make again), this was a series of ignoring several red flags and failing to assess her patient to identify life threatening issues.

I don't think she was set up for failure, but Vanderbilt did fail the patient as well. But that doesn't mean she shouldn't be held accountable for all of the mistakes she made in this situation, as well as her failure to monitor her patient, identify that she was apneic, and ventilated her. Had she done that, we wouldn't be having this discussion.

Also, was this a medication error? yes, however it's not that simple. It's almost as bad as saying 9/11 occurred because "Some people did something." And while that is technically true, it's also massively underscores the severity of the situation. Yes, the medication error (which is all too common) caused the issue, but what she was convicted of was her actions before the med error and what she did (or didn't do) after she administered it. Lets not forget, this was not an emergency situation, where if she didn't get the medication out and give it the patient was going to die...

Do I think she should be in jail? not really... This wasn't malicious, there was no intent, and sending her to jail isn't going to rehabilitate her, nor is she a danger to society. But I think a slap on the wrist isn't nearly enough of a punishment for her actions.

 

[Carlos Danger]

But don't you agree that at some point, the totality of bad decisions and poor judgement rises to the level of reckless behavior, and that reasonable person should anticipate that these actions could lead to serious harm or death?

She essentially pulled a random drug out of the drawer, slammed it, then walked away, and that was only one of several errors she made.

Nurses/medics/docs are given an immense responsibility and the tools do to good but can also cause harm. We have a responsibility for our knowledge and actions. There has to be a line somewhere in the sand that, when crossed, is just too egregious to handle with a slap on the wrist.

I don't know if her actions rise to the label of recklessness. Maybe they do, but I would not say that is necessarily so. Whatever you label it, I don't believe that spending time in prison and living the remainder of her life as a felon is appropriate.

I also don't think "she pulled a random drug, slammed it, and walked away" is a fair characterization; if it were, then prison time would be fair. But that isn't what happened. She chose the wrong drug and she broke all the rules of safe medication administration. Her actions constituted a series of errors that are indefensible, but I highly doubt they were wanton.

Again, I am personally not too concerned with any of that, because there just isn't much to discuss. We can debate whether or not her actions were reckless or evil all day long, but her errors are obvious and there isn't a lot to say about what she should have done differently. This type of thing has happened many times in the past, and they will continue to happen.....which is what brings us to what I think is much important, which is how to minimize these occurrences. And that requires us to take the focus off the individual.

 

[DrParasite]

I also don't think "she pulled a random drug, slammed it, and walked away" is a fair characterization; if it were, then prison time would be fair. But that isn't what happened. She chose the wrong drug and she broke all the rules of safe medication administration. Her actions constituted a series of errors that are indefensible, but I highly doubt they were wanton.

She pulled a drug (not the one she intended, so it's likely she didn't know what drug she pulled, since she didn't check), administered it to the patient in the cat scan tube, and left the room.... sounds like a fair characterization to me.

I don't know if her actions rise to the label of recklessness

The google definition of recklessness is "lack of regard for the danger or consequences of one's actions; rashness." Without going to the legal definition (since none of us are lawyers), do her actions meet that definition?

This type of thing has happened many times in the past, and they will continue to happen.....which is what brings us to what I think is much important, which is how to minimize these occurrences.

That's a disturbing statement... how often does that type of thing happen? when the wrong medication is administered, due to the one administering the medication ignoring all of the policies and standards that would have prevented this error? Pubmed puts the number at 0.8% (which is scary), but how many of them were preventable and could have been avoided if she had not ignored hospital policy? or basic nursing education? Yes, there were systemic failures, but at some point, the individual needs to be held accountable for ignoring the system controls.

 

[Carlos Danger]

She pulled a drug (not the one she intended, so it's likely she didn't know what drug she pulled, since she didn't check), administered it to the patient in the cat scan tube, and left the room.... sounds like a fair characterization to me.

She did not "pull a random drug". She pulled the wrong drug. Those are not the same thing. I don't think there is any evidence that she was intentionally playing Russian Roulette with medications.

So no, it isn't a fair characterization.

Yes, there were systemic failures, but at some point, the individual needs to be held accountable for ignoring the system controls.

And I haven't seen a single person argue otherwise. That she bears responsibility and should be held accountable is so obvious to everyone, in fact, that I find it bizarre that people keep feeling the need to point it out.

Continually focusing on her culpability completely misses the point of most of what I have said.

If a driver intentionally goes speeding around a curve that is well known to be dangerous and crosses the center line and kills someone in an oncoming vehicle, what is the correct response, assuming our goal is the safety of the public? Of course we hold the offender accountable by arresting and trying him. But then what? Do we just keep harping about how much at fault the offender was and how we need to punish him harshly so that fewer people speed? Or do we allow the justice system to do it's thing while separately focusing on what changes we might make to the road in the area of the dangerous curve that might make accidents there less likely? Which approach do you think is more likely to improve safety for the public?

We've made a lot of improvements to medication safety in hospitals just during my career, but medication errors still occur with an absolutely astounding frequency. There are multiple reasons for this, some of the most important of which many people just don't want to hear. Fortunately, there is a lot that can still be done, process-wise and (probably to a lesser extent), education wise. Just telling nurses to "pay attention when you are pulling meds" and threatening them with prison time if they don't is not going to help one bit.

 

[CbrMonster]

I think the weirdest part as I remember when this first happened like 2-3 years ago now. Was who the **** has ever reconstituted versed/midazolam

i mean I’ve never seen it in powder form, but I guess it could be and I realize there are several meds that come either ready to go or need to be reconstituted.

My wife made some very valid points as she works in an er, that
1, paralytics have a red top/cap,
2, Pyxis usually pops up some warnings ect
3. The reconstitutioning of the med
4. It wasnt a critical situation, it was a routine imaging, not a time dependent situation.

I do find it interesting though how harsh they are as I am by no means a lawyer or have a lot of knowledge in this subject, but it seems very harsh considering how many deaths are related to medical professional errors, yes she should have her licensed pulled and out of the field all together.

Maybe I’m being too much of a bleeding heart.

 

[johnrsemt]

Just go back to the early part of Paramedic School and Nursing school pharmacology for every us all: 6 R's (most only teach 5).
in this case.
Right Patient: Sounds like it
Right Medication: No
Right Dose: wrong medication, so no
Right concentration: Again wrong medication so no
Right Time: Probably yes.
Right Paperwork. No: I took the medication out of the Pyxsis and reconstituted it, and gave it. No way that paperwork (or computer typing) can be right.

Very few paramedics have the luxury of a Pyxsis or something similar, but most of us have learned to read the vials and carpujets, in case they are in the wrong spot in the box or bag. I carried that over to the 2 years I worked in an ED, I always doubled checked what I was pulling out of the Pyxsis; because I caught 5 loading errors that pharmacy made.

 

[ffemt8978]

Ex-nurse in Tennessee will serve no jail time in death of patient after medication error, judge rules

A former Tennessee nurse convicted in the 2017 death of a patient due to an inadvertent medication swap was sentenced Friday to serve three years probation and will serve no jail time.

www.usatoday.com

She received probation.

 

[Summit]

And if she abides by the probation, she can have a clean record.

This is sensible action by the judge.

 

[DrParasite]

sounds like a very fair and appropriate sentence.