- What is up Z Pac, it's your boy ZDoggMD.
I'm live and direct in my office.
Okay, a lot of people have messaged me
including a friend at Vanderbilt University Medical Center
asking me to talk about this thing that had been
in the local press in Tennessee
about a horrible medical error
that resulted in a patient death
at Vanderbilt University Medical Center
in December of last year, 2017
and they wanted me to weigh in on what I thought about this
and initially I was very reluctant
because I said well I kind of know what's going on here
and I don't think it's going to add a lot to the discussion.
And then I really kind of weighed it
and said wait a minute actually I think
talking about this is crucially important
and my Z Pac was right and I was wrong about this.
It does bear discussion.
Let me back up and tell you what's going on.
What's up Vanessa, what's up Suzy,
I'm reading your comments today as well.
So 2017 patient's admitted with a subdural hematoma,
bleeding on the brain.
A couple days into the admission
they decide to do a whole body scan.
I read in one of the press articles it was a PET scan,
now I don't have inside information about this.
The patient's name and the involved parties names
are confidential so I'm relying on press
and also reports from friends that are there
that say it was as bad as reported.
So what ended up happening was patient
is going to get ready to have this scan.
She's expressed a concern about claustrophobia
by report and the doctor orders a dose of Versed,
which is an an anxiolytic, benzodiazepine drug,
short acting, those of us in the know know
and for those of us who don't that's what it is.
The idea being take some of the edge
off that claustrophobia,
mild sedation, maybe not remember the procedure as well,
those kinds of things which is all perfect.
Very much standard of care for this sort of scenario.
Now the nurse who was managing this patient
before going into the scanner
went into what presumably the Pyxis,
whatever her medication dispensing device was
and couldn't find Versed on the patient's
sort of ordered medications.
Again this is my interpretation reading the press report.
So at that point she triggered some overrides
to override what was ordered
and put in the drug herself.
So she types in and we all kind of know
how these machines work, she types in the first two letters
of the drug name, V-E, Versed, trade name, right.
Not the you know the generic name
and a medication pops up, she hits okay,
takes the medication.
Well it turns out what the device auto filled
was a generic name which is vecuronium.
And those of us who know what that drug does
know that it is a neuromuscular paralytic agent.
In other words it doesn't sedate you,
it doesn't make you unconscious,
it paralyzes your muscles, including your skeletal muscles,
including your diaphragm and your muscles of respiration,
your intercostal muscles that help you breathe.
Well, this was not a good thing
because the nurse took the drug.
Apparently didn't look at exactly what it was
because most people that I've talked to
have said that vecuronium has a label on it,
a warning label big that says warning paralytic agent.
Gives the medication, administers it to the patient
and they put her in the scanner.
Now mistake number one.
Mistake number two purportedly, allegedly,
is that at this point the nurse
or whoever the staff was who were there
after administrating the drug
they did not watch the patient for signs
of effect or relaxation or reaction,
which you're supposed to do.
Instead they put her into the scanner
and then probably left the room
cause she's gonna get a scan.
The patient gets a long scan.
When they go to take her out of the scanner
she is pulseless and unresponsive
and ended up being rushed to the ICU
after I presume a code was run,
rapid response and code, and she was,
support was withdrawn a couple days later and she died.
Now let me just for the emotional significance of this,
let me describe what this might have been like
because what has effectively happened is
she's anxious about going into a scanner,
she's claustrophobic, she's already scared.
The nurse said I'm gonna give you something to relax,
which is allegedly what she said, thinking it was Versed,
and effectively gave her a drug used in executions
where she was paralyzed increasingly in an ascending way
and unable to speak, but completely conscious,
able to feel pain and discomfort and fear
but unable to move and progressively unable to breathe
until she blacked out, lost consciousness,
presumably suffered irreversible brain damage
and later died.
Let that sink in for a second.
That is the tragedy in all of this.
This patient died under torturous conditions
in a hospital, in a place where you put your trust
in other people to take care of you safely.
What happened?
How did we betray her trust?
And in the next couple of weeks
I'm going to be doing a keynote
at the Institute for Healthcare Improvement
talking to specialists in hospital safety
and I was thinking about this case more and more.
The safety mechanisms that were in place
to protect against this happening all failed, why?
And we don't know the exact details,
but in a big picture sense it's because a human being
decided to override them and then decided
that that other sort of standards of care
were not going to happen,
like monitoring the patient afterwards,
checking on the patient, seeing how the effect was,
even if you give Versed that can be a respiratory sedative,
it can drop your blood pressure, things can happen.
There should be careful followup
and watching of this patient.
So on those levels catastrophic error, catastrophic failure.
Now this actually put Vanderbilt's
entire Medicare status at risk
according to the Tennesseean who was reporting on this
and they almost lost the ability to bill Medicare,
which would have been catastrophic
because it's one fifth of their revenue.
So they put processes in place
to improve systems after this including personnel changes,
which I imagine was the nurse being fired.
And again we don't know the name of the nurse,
I don't want to know, this is the bottom line
what is at fault here and how can we do better?
Well okay, I want you to weigh in.
I want pharmacists to weigh in,
what could have been done to prevent
this dispensing of an incorrect medication?
I want nurses to weigh in, I want rad techs to weigh in,
I want everybody to weigh in and tell me
what are you doing in your facilities
to prevent this from happening.
Then we want to think about what happened here.
The thing wasn't on the order,
maybe she didn't want to call the doctor,
maybe she didn't want to have to call IT,
maybe she didn't want to get into the HR,
I don't know what was going on.
Maybe she was understaffed, maybe she was under stress,
maybe something else was going on.
There's a million reasons why the so called
Swiss cheese model, all the air holes align
and you get a straight shot to disaster.
Whereas normally these situations are in place
to prevent it from happening.
We don't know.
Here's the bottom line, there is no excuse
for an error of this type happening in 2018
in a major medical center.
There is no excuse.
And you can make all the reasons,
you can say yeah this could have been different,
we could have had a process for this,
we could have not allowed an override,
we could have done this,
but the bottom line is we should never
give this a pass on any level.
We need to work diligently to figure out what went wrong.
If it was pure human error that human needs to be adjusted
and whether that means being fired, being sued,
whatever that is we need to manage it.
Understanding if there are extenuating circumstances,
but still this patient died under torture effectively,
all right, so that being said, let's back up a second.
How was this different than the story I told
about the nurse practitioner who,
actually I have her thing here.
I have a bag
of pink wristbands for Remi Engler, her daughter,
who she was, her routine was knocked off.
We talked about this on the show,
everything, every Swiss hole aligned
where she forgot her beautiful daughter in her car
when she went to the clinic and at 4:00 PM found her
and they couldn't save her.
How is that different in terms of error
than what happened here?
You know in many ways this gets to the heart
of how human beings make mistakes,
how we need systems in place, we need training,
we need accountability, but we also need compassion
when it's necessary when it really was
all the Swiss holes aligning and we need to do better.
Now in this case what can we do?
Do we need some sort of better dispensing process,
do we need a check whenever you're giving
something like Versed, should there be better protocols,
do we need better staffing for the nurses,
better support, there's a million
different things we can do.
Let's read some comments.
So Emily Dial says our Pyxis,
which is the dispensing equipment,
also has a pop up with this medication to warn
that it's a paralytic agent, back to basics
five rights of mediation administration.
So I want to learn more about
these five rights from my nurses
cause, when I say my nurses I mean my Z Pac.
I want you to teach me about this
because I don't know about this as a doctor.
And actually many doctors don't understand
the medication dispensing pathway
and we would probably benefit from learning it.
In my facility says Stacy Lynn this would not have happened
because vecuronium is only available
in the surgical Pyxis and in the pharmacy.
The hospital needs to have better policies.
So sometimes they use, you know they can use vec in the ER,
use it as a paralytic agent along with sedation
and intubation to ventilate.
So it's not an inappropriate drug in certain settings.
So I can understand why maybe it was available, but maybe,
so Celeste says triple check, call an attending,
if you're unable to fulfill your duties that day
take the day off, there's so many things.
So I think pretty exclusively people are saying
there isn't a human excuse for this
and I think I have to agree
that you cannot give somebody a pass for this.
Now when we talked about Remi Engler
and I spoke to Nikee Engler, Remi's mom,
I got the sense that this was a deeply good person
for whom everything aligned and our foilable human brains
failed us in the most crucial situation.
And a lot of people disagreed with me,
but I unequivocally believe this
because there aren't a ton of systems
to keep us from forgetting our child in a car
beyond repetition and routine
and conscious awareness to the problem.
But a lot of times we run on autopilot.
Now in the hospital,
this nurse was not running on autopilot.
She had to go out of her way to override
the safety mechanisms.
Without then taking the extra step
of making sure it was the right medication,
checking on the patient, doing those kind of things.
So that's initially why I didn't want to talk about this
because it's like well it's pretty clear,
but you know what there is always nuance in these stories
and even if talking about it today
changes one workflow somewhere in the country
where a life is saved or disability is prevented.
There is this whole saying that like
the third leading cause of death in the United States
is preventable medical error.
I'm not sure I believe the statistic, it doesn't matter.
It's high, it's too high.
Any medical error that causes debility or death is too many
and until we have to, guys like part of this whole movement
of Health 3.0 is looking at ourselves,
putting ourselves under a spotlight saying
not everything the administration does,
not everything the quality czars do,
not everything the measurement industrial complex
does is bad.
Sometimes we need to really focus on processes
and realize that we make mistakes.
So we need systems that help us avoid those mistakes.
We need better training, but we also need fail safes.
Pilots have them.
There still could be human error,
but it has drastically decreased
and I think we can learn a lot.
We don't cookbook medicine things,
but at the same time this was preventable.
Let's read a few more comments.
Let's see April Peterson says I can't tell you
how many times I've seen nurses
not scan the patient med, say they're in a hurry
and will document it later when they sit down to chart.
Boo ya, that's it.
Doctors cut corners, nurses cut corners
when we're super busy we think you know what
I've done this so many times nothing's going to go wrong
and then it does.
And I've seen it happen with potassium orders.
I've seen people die, I've seen this happen.
And then the hospital does a root cause analysis
and they go through the whole thing
and always it's a Swiss cheese.
There are multiple errors.
Rarely is it just one human making a single mistake.
It's usually a series of things,
but again entirely preventable, entirely preventable.
Let's see why was this drug even stocked
in the radiology department.
There's a history at Vanderbilt
of these sort of shortcuts,
is there a history at Vanderbilt
of these shortcuts occurring before?
It sounds like a habitual behavior
unfortunately, Marie Daniels.
Well you do wonder if the override's that easy.
You know you do wonder.
Again Vanderbilt's a world class institution,
but in our world class institutions we make big mistakes.
The bigger the institution the bigger the mistakes.
That's what I've noticed across institutions
which means we need better policies.
That being said if I'm gonna have a complex surgery
I'm gonna go to a major academic institution.
And again this is gonna piss off come community people,
but you want people doing a procedure on you
that does it a lot and has a good safety record,
maybe takes harder cases so maybe more people die
or have bad outcomes, but adjusting for that
they're doing really well.
This actually matters.
We did a show with Dr. Rifkin from MCG Health
about care variation and saving lives
and quality improvement and guidelines and things like that.
I will share it soon again.
Let's read some more comments.
Yeah, a lot of, okay so this is what I'm gonna do.
I'm gonna leave you guys with this,
I want you to leave your comments.
I want you to have civil discussions in this section
about how we can do better.
I don't want to complain, I don't want to victim shame,
I don't want to blame people,
I don't want to do any of that.
I want to have real, actionable ideas
of how we can prevent this,
what you're doing in your institution,
what you do personally because remember this
as hard as our jobs are and as busy as we are
and sometimes we feel put upon on all sides,
we have this really sacred responsibility
to relieve human suffering.
In this case that failed
and so what can we do to live up
to the meaning and the purpose of what we do,
and sometimes that means doing mundane shit
like coming up with safety protocols
and processes and things like that,
that seem boring but they save lives every single day.
So let's talk about it guys.
Hit like, hit share and we out, peace.