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Case Study: A nurse began work as a nurse at Vanderbilt University Medical Center in December 2015. On December 24, 2017, a patient was admitted to the hospital for a subdural hematoma. Two days later, Vaught, a registered nurse, was instructed to administer Versed (midazolam, a sedating drug) to Murphey, but instead administered vecuronium (a paralyzing drug). The nurse had tried to withdraw Versed from an automated dispensing cabinet, and when that did not work, she used an override feature which allowed her access to a larger array of medications. The patient was supposed to be given Versed prior to an MRI scan, a procedure requiring patients to remain very still for 15 minutes or longer. After receiving the vecuronium, the patient went into cardiac arrest and was resuscitated. However, she had suffered permanent brain damage and was determined to be brain dead. The patient died the next day. The nurse immediately admitted the error and was fired from the hospital after an internal investigation in January 2018.
Question 1. Provide a small reflection on your thoughts regarding this case.
Question 2. What could have been done to avoid this situation?
Question 3. How could the nurse of been better supported by the hospital?
Question 4. What will you do to ensure safe administration of medications in high intensity high acuity emergency situations? |
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