The nurse was not able to find the bottle of Versed in the medicine cabinet, so she did a computer search, manual override.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 investigative report showed two instances where the hospital’s safety protocols were ignored.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.
Comment:
*The hospital pharmacy loaded the ADC with everything dangerous, thus by-passed the Licensed pharmacist participation in monitoring Paralysing agents.
*The hospital pharmacy loaded the ADC with everything dangerous, thus by-passed the Licensed pharmacist participation in monitoring Paralysing agents.
* The manager assigned a trainee to the this nurse at the time of this incident, a responsibility of the manager.
No comments:
Post a Comment