Medication Error Kills A Vanderbilt Patient | Incident Report 203


– What is up Z Pac,
it’s your boy ZDoggMD. I’m live and direct in my office. Okay, a lot of people have messaged me including a friend at Vanderbilt
University Medical Center asking me to talk about
this thing that had been in the local press in Tennessee about a horrible medical error that resulted in a patient death at Vanderbilt University Medical Center in December of last year, 2017 and they wanted me to weigh in
on what I thought about this and initially I was very reluctant because I said well I kind
of know what’s going on here and I don’t think it’s going
to add a lot to the discussion. And then I really kind of weighed it and said wait a minute actually I think talking about this is crucially important and my Z Pac was right
and I was wrong about this. It does bear discussion. Let me back up and tell
you what’s going on. What’s up Vanessa, what’s up Suzy, I’m reading your comments today as well. So 2017 patient’s admitted
with a subdural hematoma, bleeding on the brain. A couple days into the admission they decide to do a whole body scan. I read in one of the press
articles it was a PET scan, now I don’t have inside
information about this. The patient’s name and
the involved parties names are confidential so I’m relying on press and also reports from
friends that are there that say it was as bad as reported. So what ended up happening was patient is going to get ready to have this scan. She’s expressed a concern
about claustrophobia by report and the doctor
orders a dose of Versed, which is an an anxiolytic,
benzodiazepine drug, short acting, those of us in the know know and for those of us who
don’t that’s what it is. The idea being take some of the edge off that claustrophobia, mild sedation, maybe not
remember the procedure as well, those kinds of things
which is all perfect. Very much standard of care
for this sort of scenario. Now the nurse who was
managing this patient before going into the scanner went into what presumably the Pyxis, whatever her medication
dispensing device was and couldn’t find Versed on the patient’s sort of ordered medications. Again this is my interpretation
reading the press report. So at that point she
triggered some overrides to override what was ordered and put in the drug herself. So she types in and we all kind of know how these machines work, she
types in the first two letters of the drug name, V-E,
Versed, trade name, right. Not the you know the generic name and a medication pops up, she hits okay, takes the medication. Well it turns out what
the device auto filled was a generic name which is vecuronium. And those of us who
know what that drug does know that it is a
neuromuscular paralytic agent. In other words it doesn’t sedate you, it doesn’t make you unconscious, it paralyzes your muscles,
including your skeletal muscles, including your diaphragm and
your muscles of respiration, your intercostal muscles
that help you breathe. Well, this was not a good thing because the nurse took the drug. Apparently didn’t look
at exactly what it was because most people that I’ve talked to have said that vecuronium
has a label on it, a warning label big that
says warning paralytic agent. Gives the medication,
administers it to the patient and they put her in the scanner. Now mistake number one. Mistake number two purportedly, allegedly, is that at this point the nurse or whoever the staff was who were there after administrating the drug they did not watch the patient for signs of effect or relaxation or reaction, which you’re supposed to do. Instead they put her into the scanner and then probably left the room cause she’s gonna get a scan. The patient gets a long scan. When they go to take
her out of the scanner she is pulseless and unresponsive and ended up being rushed to the ICU after I presume a code was run, rapid response and code, and she was, support was withdrawn a couple
days later and she died. Now let me just for the
emotional significance of this, let me describe what
this might have been like because what has effectively happened is she’s anxious about going into a scanner, she’s claustrophobic,
she’s already scared. The nurse said I’m gonna
give you something to relax, which is allegedly what she
said, thinking it was Versed, and effectively gave her
a drug used in executions where she was paralyzed
increasingly in an ascending way and unable to speak, but
completely conscious, able to feel pain and discomfort and fear but unable to move and
progressively unable to breathe until she blacked out, lost consciousness, presumably suffered
irreversible brain damage and later died. Let that sink in for a second. That is the tragedy in all of this. This patient died under
torturous conditions in a hospital, in a place
where you put your trust in other people to take
care of you safely. What happened? How did we betray her trust? And in the next couple of weeks I’m going to be doing a keynote at the Institute for
Healthcare Improvement talking to specialists in hospital safety and I was thinking about
this case more and more. The safety mechanisms that were in place to protect against this
happening all failed, why? And we don’t know the exact details, but in a big picture sense
it’s because a human being decided to override them and then decided that that other sort of standards of care were not going to happen, like monitoring the patient afterwards, checking on the patient,
seeing how the effect was, even if you give Versed that
can be a respiratory sedative, it can drop your blood
pressure, things can happen. There should be careful followup and watching of this patient. So on those levels catastrophic
error, catastrophic failure. Now this actually put Vanderbilt’s entire Medicare status at risk according to the Tennesseean
who was reporting on this and they almost lost the
ability to bill Medicare, which would have been catastrophic because it’s one fifth of their revenue. So they put processes in place to improve systems after this
including personnel changes, which I imagine was the nurse being fired. And again we don’t know
the name of the nurse, I don’t want to know,
this is the bottom line what is at fault here
and how can we do better? Well okay, I want you to weigh in. I want pharmacists to weigh in, what could have been done to prevent this dispensing of an
incorrect medication? I want nurses to weigh in, I
want rad techs to weigh in, I want everybody to weigh in and tell me what are you doing in your facilities to prevent this from happening. Then we want to think
about what happened here. The thing wasn’t on the order, maybe she didn’t want to call the doctor, maybe she didn’t want to have to call IT, maybe she didn’t want to get into the HR, I don’t know what was going on. Maybe she was understaffed,
maybe she was under stress, maybe something else was going on. There’s a million
reasons why the so called Swiss cheese model,
all the air holes align and you get a straight shot to disaster. Whereas normally these
situations are in place to prevent it from happening. We don’t know. Here’s the bottom line, there is no excuse for an error of this
type happening in 2018 in a major medical center. There is no excuse. And you can make all the reasons, you can say yeah this
could have been different, we could have had a process for this, we could have not allowed an override, we could have done this, but the bottom line is we should never give this a pass on any level. We need to work diligently to
figure out what went wrong. If it was pure human error
that human needs to be adjusted and whether that means
being fired, being sued, whatever that is we need to manage it. Understanding if there are
extenuating circumstances, but still this patient died
under torture effectively, all right, so that being
said, let’s back up a second. How was this different
than the story I told about the nurse practitioner who, actually I have her thing here. I have a bag of pink wristbands for
Remi Engler, her daughter, who she was, her routine was knocked off. We talked about this on the show, everything, every Swiss hole aligned where she forgot her
beautiful daughter in her car when she went to the clinic
and at 4:00 PM found her and they couldn’t save her. How is that different in terms of error than what happened here? You know in many ways
this gets to the heart of how human beings make mistakes, how we need systems in
place, we need training, we need accountability,
but we also need compassion when it’s necessary when it really was all the Swiss holes aligning
and we need to do better. Now in this case what can we do? Do we need some sort of
better dispensing process, do we need a check whenever you’re giving something like Versed, should
there be better protocols, do we need better staffing for the nurses, better support, there’s a million different things we can do. Let’s read some comments. So Emily Dial says our Pyxis, which is the dispensing equipment, also has a pop up with
this medication to warn that it’s a paralytic
agent, back to basics five rights of mediation administration. So I want to learn more about these five rights from my nurses cause, when I say my
nurses I mean my Z Pac. I want you to teach me about this because I don’t know
about this as a doctor. And actually many doctors don’t understand the medication dispensing pathway and we would probably
benefit from learning it. In my facility says Stacy Lynn
this would not have happened because vecuronium is only available in the surgical Pyxis and in the pharmacy. The hospital needs to
have better policies. So sometimes they use, you know
they can use vec in the ER, use it as a paralytic
agent along with sedation and intubation to ventilate. So it’s not an inappropriate
drug in certain settings. So I can understand why maybe
it was available, but maybe, so Celeste says triple
check, call an attending, if you’re unable to fulfill
your duties that day take the day off, there’s so many things. So I think pretty
exclusively people are saying there isn’t a human excuse for this and I think I have to agree that you cannot give
somebody a pass for this. Now when we talked about Remi Engler and I spoke to Nikee Engler, Remi’s mom, I got the sense that this
was a deeply good person for whom everything aligned
and our foilable human brains failed us in the most crucial situation. And a lot of people disagreed with me, but I unequivocally believe this because there aren’t a ton of systems to keep us from forgetting
our child in a car beyond repetition and routine and conscious awareness to the problem. But a lot of times we run on autopilot. Now in the hospital, this nurse was not running on autopilot. She had to go out of her way to override the safety mechanisms. Without then taking the extra step of making sure it was
the right medication, checking on the patient,
doing those kind of things. So that’s initially why I
didn’t want to talk about this because it’s like well it’s pretty clear, but you know what there is
always nuance in these stories and even if talking about it today changes one workflow
somewhere in the country where a life is saved or
disability is prevented. There is this whole saying that like the third leading cause of
death in the United States is preventable medical error. I’m not sure I believe the
statistic, it doesn’t matter. It’s high, it’s too high. Any medical error that causes
debility or death is too many and until we have to, guys like
part of this whole movement of Health 3.0 is looking at ourselves, putting ourselves under a spotlight saying not everything the administration does, not everything the quality czars do, not everything the
measurement industrial complex does is bad. Sometimes we need to
really focus on processes and realize that we make mistakes. So we need systems that help
us avoid those mistakes. We need better training,
but we also need fail safes. Pilots have them. There still could be human error, but it has drastically decreased and I think we can learn a lot. We don’t cookbook medicine things, but at the same time this was preventable. Let’s read a few more comments. Let’s see April Peterson
says I can’t tell you how many times I’ve seen nurses not scan the patient med,
say they’re in a hurry and will document it later
when they sit down to chart. Boo ya, that’s it. Doctors cut corners, nurses cut corners when we’re super busy
we think you know what I’ve done this so many times
nothing’s going to go wrong and then it does. And I’ve seen it happen
with potassium orders. I’ve seen people die,
I’ve seen this happen. And then the hospital
does a root cause analysis and they go through the whole thing and always it’s a Swiss cheese. There are multiple errors. Rarely is it just one human
making a single mistake. It’s usually a series of things, but again entirely preventable,
entirely preventable. Let’s see why was this drug even stocked in the radiology department. There’s a history at Vanderbilt of these sort of shortcuts, is there a history at Vanderbilt of these shortcuts occurring before? It sounds like a habitual behavior unfortunately, Marie Daniels. Well you do wonder if
the override’s that easy. You know you do wonder. Again Vanderbilt’s a
world class institution, but in our world class
institutions we make big mistakes. The bigger the institution
the bigger the mistakes. That’s what I’ve noticed
across institutions which means we need better policies. That being said if I’m
gonna have a complex surgery I’m gonna go to a major
academic institution. And again this is gonna piss
off come community people, but you want people
doing a procedure on you that does it a lot and
has a good safety record, maybe takes harder cases
so maybe more people die or have bad outcomes,
but adjusting for that they’re doing really well. This actually matters. We did a show with Dr.
Rifkin from MCG Health about care variation and saving lives and quality improvement and
guidelines and things like that. I will share it soon again. Let’s read some more comments. Yeah, a lot of, okay so
this is what I’m gonna do. I’m gonna leave you guys with this, I want you to leave your comments. I want you to have civil
discussions in this section about how we can do better. I don’t want to complain, I
don’t want to victim shame, I don’t want to blame people, I don’t want to do any of that. I want to have real, actionable ideas of how we can prevent this, what you’re doing in your institution, what you do personally
because remember this as hard as our jobs are
and as busy as we are and sometimes we feel
put upon on all sides, we have this really sacred responsibility to relieve human suffering. In this case that failed and so what can we do to live up to the meaning and the
purpose of what we do, and sometimes that
means doing mundane shit like coming up with safety protocols and processes and things like that, that seem boring but they
save lives every single day. So let’s talk about it guys. Hit like, hit share and we out, peace.