Without evidence of benefit, an intervention should not be presumed to be beneficial or safe.

- Rogue Medic

Protecting Systemic Incompetence – Part I

 

We demand the lowest standards, because we are willfully ignorant and we do not want to understand. The surprise is that so many of us survive our devotion to incompetence. The loudest voices tend to dominate the discussions and the loudest voices demand that their excuses for incompetence be accepted. The rest of us don’t oppose incompetence enough.

A nurse was told to give 2 mg Versed (the most common brand of midazolam in the US) for sedation for a scan, intended to give 1 mg Versed, but actually gave an unknown quantity of vecuronium (Norcuron is the most common brand in the US). The patient was observed to be unresponsive and pulseless by the techs in the scan. A code was called. The family learned the details from a newspaper article, not from the hospital.
 

A Tennessee nurse charged with reckless homicide after a medication error killed a patient pleaded not guilty on Wednesday in a Nashville courtroom packed with other nurses who came in scrubs to show their support.[1]

 

The nurse intended to give a medication that should be limited to patients who are monitored (ECG and waveform capnography), because different patients will respond in different ways. This is basic drug administration and deviation from that basic competence may even have been common in this Neuro ICU (Neurological Intensive Care Unit). We demand low standards, because we do not want to understand.

We don’t need to monitor for that, because that almost never happens.

Except these easily preventable errors do happen. And we lie about it. We help to cover it up, because we demand low standards, regardless of how many patients have to suffer for the benefit of our incompetence.

This is a common argument used by doctors, nurses, paramedics, . . . . It makes no sense, but we keep demonstrating that we don’t care.

The people in charge should act responsibly, but they delegate responsibility and we reward them.

Back to the hospital, Vanderbilt University Medical Center (VUMC) is a university medical center, so the standards should be high. VUMC was founded in 1874 and is ranked as one of the best hospitals in America.

There is a drug dispensing machine, from which less-than-killed nurses can obtain almost anything and administer almost anything, without understanding enough to recognize the problem. This is an administrative problem. This was designed by someone with no understanding of risk management.

The over-ride of the selection is not the problem, because emergencies happen and it is sometimes necessary to bypass normal procedures during an emergency. Ambulances are equipped with lights, sirens, and permission to violate certain traffic rules for this reason.

Some of the many blatant problems are:

* The failure of the nurse to have any understanding of the medication supposed to be given

* The failure of the nurse to recognize that the drug being given was not the drug ordered.

* The failure of the nurse to monitor the patient being given a drug for sedation.

* Most of all, the failure of the hospital – the nurses, the doctors, the administrators, to try to make sure that at least these minimum standards are in place.

* How often do nurses in the Neuro ICU give midazolam?

* Why is a nurse, who is clearly not familiar with midazolam, giving midazolam to any patient?

* How is a nurse, working unsupervised in a Neuro ICU not familiar with midazolam?

* What kind of qualifications are required for a nurse to give sedation without supervision?

* Since this nurse was orienting another nurse, what qualifies this nurse to orient anyone?

* Given the side effects of midazolam, why was midazolam ordered without monitoring?

* Given the side effects of midazolam, was it the most appropriate sedative for use in a setting where monitoring is going to be difficult?

* Was it the more rapid onset of sedation, in order to free up the PET scan more quickly and/or avoid having to reschedule the scan, that led to the choice of midazolam?

* How well do any of the doctors understand the pharmacology of midazolam if they are giving orders for a nurse to grab a dose, take it down to the scan, give the drug, and return to the unit, abandoning the monitoring of the patient to the techs in the PET scan?

* This is not a criticism of the techs in PET scan, but are techs authorized to manage sedated patients?

* Even though they will often scan sedated patients, are the techs required to demonstrate any competence at managing sedated patients?
 

The nurses being oriented apparently thought that it is customary to give sedation:

1. without even looking at the name of the medication

2. without confirming by looking at the name again, it before administration

3. without double checking with a nurse, or tech, that the label matches the name of the drug to be given
 

How many of the doctors, responsible for the care of ICU patients, would agree to be sedated, without being monitored, and to have their care handed off to PET scan technicians?

Why didn’t the doctors and nurses see this as a problem before it made the news?

If the problems were reported, nothing appears to have been done to address the problems beyond the usual – Nothing to see here. Move along. or That’s above your pay grade.

That is the primary point I am trying to make.

The problem is well above the pay grade of the nurse.
 

Here is the part that experienced nurses have jumped on immediately:

Why did the nurse think that midazolam needs to be reconstituted?

Vecuronium (most common brand name is Norcuron) is a non-depolarizing neuromuscular-blocker, which comes as a poweder, that needs to be reconstituted.
 


Image source
 

1. Read label instructions?

This nurse has repeatedly demonstrated a need to be supervised, but those responsible for that supervision have apparently ignored their responsibilities in a way that far exceeds any failures by this nurse.

Is it possible that this is a one time event and that the nurse has behaved in an exemplary manner at all times while around doctors and other nurses before this day? It is possible, but the number and severity of the failures on the part of the nurse strongly suggest a pattern of not understanding, not caring, or both. I suspect that any lack of caring is due to a lack of understanding, because I have not yet lost all hope in humanity.

Footnotes:

[1] Nurse charged in fatal drug-swap error pleads not guilty
By Travis Loller
February 20, 2019
Associated Press
Article

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