The Scapegoat

I have spent the morning reading and re-reading the complaint survey related to the death of a patient who gave Vecuronium instead of Versed at Vanderbilt University hospital. Clearly the nurse made a costly mistake. She was prosecuted and convicted of two felonies.

The complaint survey was conducted almost a year after the death. Vanderbilt Hospital did not report the death so there was no reason for the surveyors to conduct a complaint survey.  The death is rumored to be reported by an anonymous tip. The irresponsibility demonstrated by Vanderbilt university in not reporting a patient death due to a medication error is a clear violation of minimum standards but don’t worry.  They have changed their policy. 

This tragic death occurred when the patient was sent for a PET scan. It is noted that the patient was received in radiology awake and alert but anxious.  That’s when the Versed was ordered.  Why pray tell, did the response to the state survey focus so intensely on the transport policy.  

Radanda Vaught gave what she believed to be Versed.  The radioactive dye had already been given and the patient was placed in a room while the dye dispersed throughout her system.  

The radiology techs acknowledged that video monitoring was in place but the cameras could not discern the movement of breathing in a patient.  Not wanting to sound callous, a patient who dies from Versed looks about the same as one who died from Vecuronium.  I can afford a Ring Doorbell and it would let me know if someone was breathing.  Can Vanderbilt University Hospital not afford a trip to Best Buy?  Even if they shelled out the cash for quality equipment, the best camera in the world is not a Registered Nurse. 

Something that was completely glossed over in all the chatter is the surveyor’s account of the interview with the radiology tech.  Please read carefully.  I have chosen to not summarize in case I am wrongly interpreting this.  

Because surveys are public information, names are substituted and frankly it can be confusing.  My assumption is the nurse who was referred to as the patient’s nurse was the one assigned the patient that morning and the nurses sent were the resource nurse (Vaught) and her preceptee.  Please read and let me know if you interpret it differently because it appears as though an ICU nurse told radiology that the patient did not require monitoring after the administration of Versed.

I don’t make this stuff up.  This is extracted from the Versed package insert in one of those ominous black boxes.

Intravenous midazolam should be used only in hospital or ambulatory care settings, including physicians’ and dental offices, that provide for continuous monitoring of respiratory and cardiac function, e.g, pulse oximetry. Immediate availability of resuscitative drugs and age- and size-appropriate equipment for bag/valve/mask ventilation and intubation, and personnel trained in their use and skilled in airway management should be assured.

So I have questions.  If the patient had her pulse oximetry monitored or a portable ekg, would an alarm have alerted staff to a problem before a transport tech happened to walk by and notice the patient was not breathing?  Monitors do not take the place of a nurse but they are better than nothing.

So, the fact that the wrong drug was given probably didn’t affect the outcome because if Versed was given according to evidence based practice standards, monitoring would have been in place and lots of alarms would have sounded and there would have been an ambu bag and someone qualified to intubate right there. 

Back to the transport policy which has been revised to include critical care patients.  As of November 27, 2018 all patients will be ‘transferred with the equipment and supplies, and staff appropriate to monitor and support the patient’s physiological needs’.  What on earth did the policy say before it was revised.

The Transport Policy also includes provisions that after arrival at the receiving department/unit, if a patient requires continuous monitoring, a clinical staff member is required to be available to receive handover of the patient pursuant to the Hospital’s CL SOP – Clinical Handover Communication.  Who might this clinical staff member be? I would hope a Registered Nurse experienced in conscious sedation would be the least qualified person allowed, assuming anesthesia wasn’t available.

Remember, the radiology department refused to give the Versed because no nurse was available to monitor the patient.  This change in policy doesn’t appear useful.

The argument against Ms. Vaught is that she fell short of accepted nursing standards.  There is no doubt in my mind.  There is also no doubt in my mind that Radonda Vaught, given the chance to practice again, will never make this or a similar mistake again.  

Vanderbilt University Medical Center, on the other hand, will continue to suffer the very bad outcomes of disinterested leadership concerned with image rather than patient care unless something has changed or will change.  

Don’t let this discourage you from reporting errors.  Ms. Vaught’s patient is not the only one who died from a med error.  Every day, med errors harm patients.  Home Health and hospice are not exceptions.  Let this be a reminder to reconcile your meds, be mindful and learn from your mistakes before they result in the death of a patient.