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My partner is a physician. This particular case has come up at social gatherings with other medical professionals. In regards to the headline, none of them have
by wl 5y ago
My partner is a physician. This particular case has come up at social gatherings with other medical professionals. In regards to the headline, none of them have expressed worry they'd be next. Instead, the uniform response is that the the nurse was actively and criminally stupid and that the death was particularly horrific.
Specifically:
* Imagine being fully conscious but being unable to move or breathe. Imagine the panic as you suffocate. That's how this patient died.
* The drug the nurse intended to give (Versed) was a sedative. The standard of care for sedation includes monitoring. There was no monitoring as there should have been. A simple pulse oximeter would have caught the error before it was fatal.
* Vercuronium is especially dangerous and thus tightly controlled. Only attending anesthesiologists and emergency medicine physicians give it independently. Residents give it under supervision. The only nurses who give it are CRNAs under direct supervision. The nurse had to go out of her way to get around restrictions designed to prevent her from giving it. The drug has warnings. And she had to mix it up herself, unlike every other time she gave Versed.
- kadoban 5y ago> The nurse had to go out of her way to get around restrictions designed to prevent her from giving it. From the article, it sounds like those restrictions were on the level of severity of a click-through that one is required to do many times a day. Those quickly become meaningless.
- c22 5y agoOne time at the doctor's office I watched in awe as the nurse quickly dismissed the exact same repeating dialogue box over half a dozen times in a row by clicking "cancel" then performing the same action to summon the box again. The text in the box was a bit dense, but after seeing it many times I had managed to read the entire paragraph over her shoulder. I gently suggested she update the field the error was complaining about to a valid setting and we were on our way.
- fnordpiglet 5y agoAny monitoring and alerting system with spurious false positives leads to “negligence.” I can’t speak to the other aspects but definitely the UX aspect is frightening to consider. Normalization of deviance can hardly be blamed on the individual.
- didgeoridoo 5y agoYour second point is perhaps the most salient in establishing neglect. The patient would have immediately stopped breathing and moving, and her lips would have turned blue. Anyone paying the slightest bit of attention would have seen that this is not the expected reaction, and intubated until the vec wore off. Even if the nurse had administered the correct medication, this patient would have been in danger. Versed is a benzodiazepine, and not without its own risks — especially in an elderly patient. What was this nurse doing paying so little attention to a patient she thought she had just sedated?