Nurse’s Error Leads to Patient’s Death, Threats of Jail Time: When Medical Errors Are Criminalized.

3 thoughts on “Nurse’s Error Leads to Patient’s Death, Threats of Jail Time: When Medical Errors Are Criminalized.”

1. Criminalize medical errors and pretty soon no one will be going into healthcare fields.

   Virtue signaling on steroids.

2. I think we can see an automatic problem with the ability to over-ride the Accudose system in any case where a nurse or person administering a drug cannot find a record of the medication in the repository of the machine. This is automatically a problem. (Pun intended)

   Years ago, I saw a TV movie of some actors framing our first Mars colonizers. In one of the episodes a botanist was having a kind of fugue state, where he imagined himself in his own (Earth) backyard. He was depressed and was probably not a good match to be a first colonist. In the TV movie he easily unlatched the door and walked directly out into Mars, depressurizing the entire colony and causing hundreds of deaths.

   I could NOT understand why or how a simple door latch would be allowed on an exit door of a Mars colony habitat that would allow for a catastrophic depressurization?

   Nor can I understand how unreliable the Accudose system is to allow someone to withdraw a dose of a dangerous muscle relaxant used mainly by anesthesiologists (or executioners).

   Nobody is asking the question: “How and why would an automatic drug dosing system be allowed to be easily over-rode?” Why no warning system for dangerous drugs? Who designed this contraption? Wasn’t an accident just waiting to happen?

   How is it that it takes an elderly retired DPM to realize this? Do they want to send an employee to prison for design incompetence? What about the people who engineered this?

   Michael M. Rosenblatt, DPM

3. The situation described, substituting vecuronium for versed has happened several times over the decades. The newspaper article about the trial providing another tid bit of information… the pharmacy dispensing machine had recently had some software updates.
   As a retired anesthesiologist, what should happen, given that critical event analysis always shows that there is more than one factor involved in these circumstances is as follows:
   1)Vecuronium should simply not be available in any environment other than the OR and the adult ICU. I highly question the need for it in the ER, and frown on ER physicians using it to facilitate intubation in emergency circumstances, because they do not know if they can intubate a patient until the carefully examine the airway and know in advance that they can intubate the patient. In the OR we have all equipment immediately at hand to support an airway including the anesthesia machine. ERs seldom have all that we have in the OR. So restrict the drug to only those places where it needs to be.
   2)Overrides for vecuronium should never be permitted under any circumstances. This is a matter of programming the machine.
   3)Any override if it is decide that this is necessary MUST have a pharmacist involved to authorize the override with direct verbal communication between pharmacist and nurse. If the pharmacist is at home, then the pharmacist on call MUST be contacted to discuss this override before it is authorized.
   4)Only fully authorized physicians should have the ability to order vecuronium in the first place.
   5)Versed should be prescribed by its generic name midazolam. Requesting nurses must be trained to get it from the pharmacy dispensing machine by its generic name.
   6)Every vial of vecuronium brand name Norcuron should have a pharmacy label on it indicating that it is for paralyzing patients and is not for sedation, or for routine use.
   7)Ongoing pharmacy education of the nursing staff in regard to medication errors should be done routinely because nurses get precious little pharmacologic training in nursing school.
   8)The next issue in this case was a failure to monitor. Any time any anesthetic drug, like versed or vecuronium is used, the patient by protocol must be on monitors for pulse oximetry, ECG, End tidal CO2 and non invasive blood pressure. This monitors have been required for decades in the OR and recovery room and are part of the anesthesia standard of care. If these monitors had been in place, a decreased O2 Sat and End tidal CO2 would have been detected BEFORE the patient arrested.
   9)There was also a failure to resuscitate. The patient should have been treated with a bag valve mask Ambu bag and mask so that the patient could have been ventilated until they recovered from the vecuronium whether naturally over time or with a reversal agent such as neostigmine and atropine.
   10)The hospital chose to put all of the blame on the nurse, and ignored all of the other critical event analysis information.
   I put many if not most of these steps in place in the facilities where I chaired departments.
   Safety is a culture. It is multi layered. It requires figuring out in advance how people will screw things up and preventing it by putting multiple different safety protocols in place. In this case it is possible that they had those protocols in place BEFORE the pharmacy machine software updates! But the hospital not stepping up and admitting its fault in this case, permits a possible culture of blame and not safety to continue to exist.

   Finally the criminalization of medicine on multiple different fronts, not just this one, contributes to the enormous stress that clinicians endure every day. It is flat out wrong, doesn’t protect society and leads to a further decrease in those who leave the medical and nursing professions prematurely. Malpractice cases are bad enough. This is worse. This was, by description a nurse that was otherwise well trained, was supervising a trainee, and now after one terrible mistake, she will never work as a nurse again, with a felony conviction on her record. Even though she is going to go on probation, and not prison, she will never work in any field requiring a license, with a felony conviction ever again. The entire Vanderbilt hospital system failed her (IMHO), and failed the patient, by not creating a secure enough safety environment. This exact drug swap has happened before, and will happen again, because the steps that I have outlined have never been put in place. across the healthcare systems in the US, though they should be.

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