The family of an elderly woman killed by a medication mix-up at a Tennessee hospital has filed a wrongful death suit.
A 75-year-old woman, whose name has not been released, was experiencing headaches and difficulties with her vision. She was admitted to Vanderbilt University Medical Center (VUMC) on Dec. 24, 2017.
The woman was scheduled to undergo a PET scan, or positron emission tomography scan, on Dec. 26.
A PET scan involves placing the patient in a tube just a little wider than a person’s body. Because the patient feared feeling claustrophobic, she requested anti-anxiety medication for the time of the scan.
The nurse, whose name has also not been released, was supposed to administer two milligrams of the sedative Versed.
But the nurse grabbed the wrong drug.
Instead of Versed, the nurse injected the patient with a paralytic called Vecuronium.
Nashville attorney Brian Manookian, who is representing the victim’s family, told NBC News, “The nurse who went to retrieve the Versed in this case instead retrieved the lethal injection drug.
“It’s the drug used in the lethal injection protocol in Tennessee and other states to execute murderers and serial killers.”
After the Vecuronium was injected, the patient went into cardiac arrest. She died two days later.
“She would have fully experienced torturous, searing pain as her lungs shut down, and she was unable to verbalize what was occurring being fully awake and aware the entire time,” Manookian told NBC.
Vecuronium is one of the three drugs administered by the state of Tennessee when executing criminals by lethal injection, the Tennesseean reported.
In executions, the state uses a drug called midazolam to put the patient to sleep, and then uses vecuronium bromide to paralyze the patient’s lungs. The final drug, potassium chloride, is supposed to stop the patient’s heartbeat.
There is much controversy over the method, as observers say convicts can be seen to be suffering agonizing pain despite the midazolam.
Without the midazolam to ease the pain, the patient in this case might would have suffered horribly.
According to The Tennesseean, the Centers For Medicare and Medicaid Services investigated the incident and issued a report which detailed how the error was made.
The nurse was not able to find the bottle of Versed in the medicine cabinet, so she did a computer search. The nurse then hit the manual override which unlocked more powerful—and more dangerous—drugs.
The nurse typed in the letters “VE” and went to the location suggested—the location of the lethal drug.
The nurse administered not the two milligrams of Versed, as had been prescribed, but 10 milligrams of Vecuronium—enough to shut down the elderly woman’s body.
The patient was taken directly to the PET scan. Because the drug had paralyzed her, the patient did not exhibit any signs of distress. Medical staff estimated that the patient was lying unresponsive but conscious in the machine for as long as half an hour before someone noticed that her body was shutting down.
A different nurse noticed the error later that day and told doctors. By that time, the patient had suffered irreversible brain damage. The patient was kept alive on a breathing machine initially, until a decision was made to turn the machine off.
Safety Protocols Ignored
VUMC is one of the largest and best respected hospitals in the area, the Tennesseean reported. Even so, the error was so serious that Medicare contemplated stopping all reimbursement payments to the hospital.
VUMC gets about one-fifth of its income from Medicare reimbursement.
The investigative report showed two instances where the hospital’s safety protocols were ignored.
First, the nurse deliberately turned off the control which kept the more powerful drugs segregated from those used more commonly.
Second, nurses are supposed to monitor patients after administering medication in case the patient has a negative reaction. Even the prescribed medication could have cause an allergic or some other damaging reaction.
In this case, the patient was injected with Vecuronium and then immediately placed inside the PET machine, where no one could see her.
VUMC has recognized these error and began crafting a new set of safety protocols to make sure an error of this sort could not be repeated. That plan was announced on Nov. 29.
John Howser, a VUMC spokesman, said the plan was submitted in November and had been revised as recently as this week. The hospital had already taken “necessary corrective actions,” Howser said.
“In reviewing the event at the time it happened, we identified that the error occurred because a staff member had bypassed multiple safety mechanisms that were in place to prevent such errors,” Howser announced, according to the Tennessean.
“We disclosed the error to the patient’s family as soon as we confirmed that an error had occurred, and immediately took necessary corrective actions (including appropriate personnel actions).”
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