Music.

Welcome to the Pre-Accident Investigation Podcast.

I'm Todd Conklin.

How are you?

So remember, I've been promising all these incredible podcasts and delivering, I might add.

We're definitely delivering on them as well.

This one, I think, is among the more amazing.

It's a two-parter, so I'm just going to break it to you gently.

And it probably should be a three-parter, but it's a two-parter.

And we're going to have a really interesting discussion today because we're going to hear a story of a failure.

And then next week, we're going to talk about sort of what appeared in that failure post-event.

So this is right in our wheelhouse.

It's right where we all live.

And I think you'll find this to be a very, very interesting podcast.

Tell your friends, invite anybody.

Everybody's welcome.

Doesn't cost you anything.

I'm always glad you're here.

Everything's great here.

I just, I don't want to shitty chat too long because we're going to talk to Redonda Vogt.

And Redonda Vogt is the nurse at Vanderbilt that was criminally charged for a medical error.

And we've talked about it a bunch on this podcast.

And Redonda caught up with me and said, hey, we should chat.

And I said, hey, we should.

And so, hey, we did.

And it is a remarkable conversation.

But it needs to start with Redonda telling her story, her context-rich story.

And so that's what we're going to do today, is listen to the story of a failure, a horrible and unfortunate thing.

But we're going to listen with the ears of someone who wants to restore the system and learn from it.

And that is the key thing Redonda brings to the table is the amount of energy that she has around this story is remarkable.

And I'm so proud of her because I think it would be easy just to kind of crawl into a hole, but human beings are incredibly resilient and there's much to learn and she has much to teach us.

So without any further ado, this is part one of this episode, let's listen to the story of a failure that's filled with many, many, many pieces of important context.

I got so involved in your case just because it took such a weird, weird turn that, you You know, and I'm just so, I can't even tell you how motivated I am to make sure people don't criminalize human error.

I mean, that's just crazy.

I think that's very...

It's hard to understand unless you are close to safety or you've been close to someone who's walked in that realm, you know, touched their toe in the fire.

It's hard to understand that that's really not the right path.

And I don't know what it is about my particular case because I'm not the first person or the last person that's ever been charged with negligent homicide as a result of a death of a patient.

There were some nurses, I think, in Denver in the 90s.

Julie Tao was a nurse in Wisconsin in 2006-2007.

And since my case, there have been a couple of other nurses who have been charged.

I don't think that they were actually convicted, but there were attempts to bring charges against multiple other nurses.

And I don't think this went through.

But I think maybe just the timing of my particular case.

Maybe, you know, some other involvements of some big names.

You know, I don't really know, but it did strike a nerve with people, didn't it?

Yeah, it sent a shiver through the community for sure.

And that kind of started everything.

And I think it was kind of a multi-phase shiver.

People were just profoundly sympathetic and felt so bad for what you were going through, which absolutely is an important thing to think about.

And at the same time, they were so worried about what was happening to the world, especially in medicine, because medicine, I mean, it's just such a bizarre Frankenstein of an organization.

It really is.

And from you looking, from the outside looking in, I'm sure it really does seem that way.

And for me, from the inside looking out, I'm seeing it more and more how it does look like this very bizarre Frankenstein industry.

Industry like it's you know we we offer services to people but it's not like you have much of a choice yeah really because most of the time you're just going to wind up you don't really plan to wind up in the health care system and the goal is just not to die the goal is to get out being better right it's not like i get to choose which airline i want to fly because i'm going to go somewhere i have choices in that it doesn't seem the same in health care and the stakes are attire and we really don't work together as well as we should and we operate in a lot of silos there's a lot of silos there's a lot of this kind of behind closed door sort of competition you have insurance providers that create a whole nother level of complexity and then not to mention cultural differences just from unit to unit hospital to hospital across different parts of the of the country and, So complex.

So complex.

Well, tell us your story.

How much time do you have?

You know, we probably ought to be done in eight hours.

So.

Okay.

I think we can do it in eight hours.

No, realistically, how much, how much time do you have?

You know, why don't you tell me what you'd like to know?

Why don't we, why don't we start there?

Because I feel like that I could tell you a lot of things, but you're going to know what your audience is going to want to know best.

So you interview me.

So how about that?

That's perfect.

Like, we're interested in a couple of things.

One is your story, how you got to the place where you got to, which is really interesting.

And then to an extent, your take on what happened, the context-rich environment in which the failure happened.

That's really interesting.

And then after we kind of established that baseline, we're good to go.

But we're recording now.

I mean, we're doing the podcast.

This is what it feels like.

Live on the podcast with Todd Gunklin.

That's right.

There you are.

So, all right, well, I'll try to give you the most context-rich version of the series of events that led up to this mistake, which, as you pointed out, is the most uninteresting part of all of this happening.

You're right.

It always starts with a mistake, but there were a lot of things that led up to the mistake itself that really played an important role in allowing this to happen.

So whenever I started at Vanderbilt, that was 2015.

I was pretty younger, maybe nine months of experience.

But that was the place I knew I wanted to be.

I like the culture and the environment there, very rich in learning.

And that, you know, I wanted to be better at what I was going to do.

So that was my goal.

I started there in the neuro ICU in 2015, October timeframe.

And then when this medication error happened, that was December of 2017.

So I've been there for two years and two months, roughly.

My role for that day was to be a helping nurse.

I did not take patients directly.

I was also not the charge nurse for the unit.

This was kind of a unique role that's not very common in most settings.

But again, Vanderbilt was kind of progressive and we tried to do things better.

So having this help all allowed me to be present and available to help other nurses while they were taking care of critically ill people and needed an extra set of hands.

So, This particular day, I think it was my third day in a row, it was the day after Christmas.

You know, so anytime there's plenty of statistics that show that error tends to be more frequent after our third shift, which is why we try not to work more than three shifts in a row in healthcare.

But I was on that third shift, daytime.

You know, the unit was staffed just fine.

The one thing that we were having complications with our system, our electronic health record system, our EHR, which had at that point been updated to a software called eStar.

So it was a combination of Epic and Vanderbilt's proprietary EHR called StarBriver.

They implemented that back in November of 2017, so sometime maybe six to eight weeks prior to this event.

that was a huge undertaking because Vanderbilt is a very, very large facility.

It is the single largest private employer in the state of Tennessee.

That gives you any idea of how very large it is.

It's been there in Nashville for almost 200 years.

We touch far and wide outside of just Nashville.

It's not just this one hospital.

In Nashville, there are many, many, many, many outlying facilities that we touch.

We also bring patients in from you know, multiple states away because of the way Tennessee is shaped.

We're close to Kentucky, we're close to Alabama, Mississippi, Arkansas, Georgia.

So we serve a large, a large group of people, lots and lots of moving pieces.

So to install a piece of software this huge across an institution that big was certainly an undertaking.

My initial perspective is that things were working great.

I really liked it.

But there were some problems.

And the one thing that we were seeing in our unit was this delay in drug orders coming to our medication dispensing cabinet, this, you know, locked electric machine that holds all of your medication.

This was a known thing that we'd been working around.

And for a while.

So it had been a problem for a while.

It had been a problem really since we launched E-Star, which again was I think maybe the second week in November.

Okay.

And the thing is there wasn't really a rhyme or reason to the delay.

It wasn't with every drug order.

It wasn't with any specific type of drug.

It wasn't related to a specific patient.

It wasn't related to a type of order.

And the type of order, I mean, is it a routine drug that's going to be given on a scheduled time?

Is it like an as-needed drug for, you know, like when you get for pain or nausea?

Is it a stat drug to be given relatively quickly for an urgent or emergent situation?

Those are the different types of orders.

So it wasn't really specific to anything.

We weren't really sure why certain orders would just be delayed.

They might be delayed by minutes.

They might be delayed by hours.

So our workaround for that was to utilize an override function.

There are certainly things you want to check along the way to make sure that the process is working correctly before you utilize override.

And those things have been done in the previous weeks.

So, for example, pharmacy would have needed to then check with to say, hey, is everything good on your end electronically?

Have you verified that this order is correct for this patient, that there are no issues with allergies, et cetera?

And then pharmacy electronically sends it over to be released via the dispensing cabinet.

There were no issues that could be found along the way.

So it was just, well, we're going to have to figure this out.

In the meantime, our solution is to work around it and utilize the override function to get these medications to patients in a timely manner.

So that's what we did on this particular day.

I get a call from a nurse who's taking care of some patients in our step-down portion of our unit.

He says, my patient is already downstairs in radiology.

She's there for a PET scan.

She needs a medication for anxiety.

Can you go give this medication to her?

Because I can't leave.

I'm watching my other patients.

And also the nurse next to me that would relieve me is away for a few moments.

So I'm watching their patients as well.

So, for context, it was not super common for our patient population to ever leave our unit without a nurse.

Certainly, our ICU patients would never leave without a nurse or without all of the monitoring things to go with them.

This was a step-down patient.

She normally would not have left, but she was getting better.

And so earlier during the day, doctors had discontinued some of these additional orders that would have required her to stay on a monitor or leave the, you know, have a nurse with her if she left the unit.

So her continuous monitoring was DC'd earlier in the shift.

The physicians knew she was going to be going downstairs to radiology for this test stand, which is far, far away from our unit.

And they read odors for her to be off the floor without a nurse, meaning someone who simply transports patients to pick her up, take her there and bring her back.

There was also some knowledge of her having an issue with anxiety.

I'm unaware of this, but I found out later those things weren't addressed in a timely manner.

Otherwise, she could have gotten an oral medication and all of this would have never transpired.

But for whatever reason, that wasn't addressed.

So we found ourselves in a position where this patient is already downstairs in the radiology department.

The radiology department is calling her primary nurse to say she's anxious and she doesn't feel like she can complete this scan without some sort of medication.

She has claustrophobia and anxiety.

So he calls the physician.

The physician writes an order for IV versus IV means it goes into your IV.

It's a liquid that goes directly into your vein.

It's not a pill that you take.

So he writes an order for IV versus the nurse calls me, asks if I can give it.

That's where we are.

So I get some information about this patient.

Where is she?

He says she's in PET scans.

Okay, what's the drug?

How are she giving?

Okay, I find out about that.

I'm asking about taking a travel monitor downstairs and staying with her.

And he says, you know, this is when he relays the information to me.

No, the patient's off the floor, unmonitored, without a nurse.

The doctor has discontinued her monitoring, and he wrote the order for her to be off the floor by herself.

And he also wrote the drug order, same position, written all three orders.

Again, I don't know this patient.

My job is helping with roughly 36 other patients.

So I don't have any personal information about this patient that would have helped me make a better decision other than what I can see briefly looking at her file and what I'm being told.

So I took this young man's word for what it was, even though I had kind of a gut feeling that I should have done something different, which was to take a travel monitor with me, which would have meant that I would have stayed with her.

So at this point, I'm looking for the medication, right?

Now we need to get medication because we need to go because we're not in an emergent situation, but the time is ticking.

The reason the time is ticking is because this patient needs a specific type of radioactive glucose running through her veins in order to get her PET scan.

And you have roughly 45 minutes to an hour after that's given intravenously to have the patient in the PET scan.

Your body needs to be metabolizing that glucose in order for the scan to work properly and it takes about 45 minutes to an hour for that to happen well radiology was not documenting electronically when they gave their medications because they were still using paper which means we weren't able to see exactly when our 45 minute window started just knew that we were in sort of a hurry because if this didn't happen what i had been told is that this was going to delay her discharge planning because they really needed the evidence.

They needed the results of this to make a decision about what to do with her plan going home.

So this was, we were in a hurry.

So I go to the medication defense in cabinet.

I pulled up her profile.

Her name is Charlene Murphy, by the way, and we are not bound by HIPAA, so I would prefer to call her by her name if that's okay with you.

Sure, sure, sure, sure.

I pulled up Ms.

Murphy's profile and I'm looking for the specific drug.

I can't find it.

It's not there.

And we have certain order types that I was telling you before.

Routine orders, stat orders, PRN orders.

Those would be the three sections that you could look into to find various drugs for birth.

It's not there.

I get off the phone.

I call the nurse back and I say, hey, I don't see the drug here in the dispensing cabinet.

Can you verify that it's already been placed by the physician?

Was this a verbal order that he told you or has it already been written?

He says, no, it's there.

It's in our computer system.

It's on her mar.

I've already acknowledged it electronically.

It's there.

I hang up.

I go back to the machine.

Again, it's not there.

So I leave the machine.

I go to an empty patient room.

These are different.

This machine with medications, to give you some context, it just houses medication.

You're not really going to be doing anything else with this except for pulling medications out of a giant lock.

Gotcha.

So I go to an empty patient room because what I actually need to see is a, all of the orders that are present in her electronic health record system.

I need to actually look at the drug itself and see that it's ordered and it's there and lay my eyes on this order.

So that's what I do.

I pull up Ms.

Murphy's electronic health record.

I go to her medication administration record, which has a list of all of the drugs that she's been ordered during her space.

And I can see it at the top.

There it is.

Very clearly written.

Sir said, one to two milligrams is needed for anxiety for PEP scan.

So at this point, I grab a sticky note.

I've got a sticker with her medical information, her MRN number on the back of it.

I grab a plastic bag that you would send lab samples in out of a stock cabinet in this empty room.

And I take a pink Sharpie, which a lot of times you see nurses, they carry a little Sharpie on their badge so they can quickly write on things.

I wrote this order down on the outside of this plastic clear lab bag in my pink Sharpie.

Trans-Savie was on the bag.

And then I grabbed some supplies that I would need to give her the medication, which is just empty saline flushes, like just those little 10 ml syringes that have normal saline that you just, it's not a drug.

It's just basically water, essentially for claimant's terms, to push the medication in and then to push the medication behind.

So I grabbed a few of those.

I grabbed some alcohol swab.

I grabbed the type of needle that I would need to go into a vial and withdraw medication.

I put all these things in the bag.

And as I'm looking through her medication administration records, just all the drugs that she's been ordered, I can also see that she has been ordered to receive first aid for a previous radiology procedure sometime in the 24 hours prior to that moment.

Thank you.

Again, for context, Versed is not typically the medication we would have given for a radiology procedure off-site.

That would have been something we would give pretty commonly in our room for our ICU patients, our sickest of the sick patients when we were doing procedures or cessation or something in the patient's actual room with a team of people.

If we were going to be giving an IV medication for anxiety in radiology, the more common drug that we would have given would have been Ativan.

Again, I don't know this patient.

I don't know her history.

Simply kind of gathering clues now.

And so my context clue is that the reason they must be selected for that is there's a preferred reason for this patient.

Because now that I can see her orders, they've ordered it twice for her.

So this must be the preferred drug of choice for whatever reason for this patient.

Again, not terribly uncommon that you would give it for sedation.

It's just that there are other options that we would have given more often than that.

So I have this information now.

I can see that she's gotten this med before.

I can go back to the dispensing cabinet and try for a third time to find this medication and get it to her or get it for her.

At this point, I'm back to the medication dispensing cabinet.

I have a new hire nurse that's with me, following me over the course of this day to observe what the help-all role is capable of doing in our unit.

We're also going to do a separate task in the emergency department while we're walking downstairs, something we've been asked to do around the same time.

And so instructing him to gather some things for that.

And we're in this open hallway in the middle of our unit.

He's at the nutrition station grabbing ice chips and crackers.

I'm across the hall at our medication distancing cabinet looking for this medication.

Another little piece of context.

And again, these aren't excuses.

It's just kind of setting you up for how all these things happen.

Medication errors often start when you're pulling the drug, especially when you're giving the wrong drug, right?

So that process is kind of, I can sort of equate it to what you guys might call like a stop the line or, you know, you stop here and it should ideally in a perfect world.

When you are retrieving medications, you should be in a quiet area.

In a perfect world, those dispensing cabinets would be in a room by themselves.

That would be the only thing in there.

Right.

And there would be certain rules about not engaging in conversation or disrupting someone while they're pulling medication.

That's kind of a big thing in health care, but we're not so great at doing it across the board.

These medication dispensing cabinets were out in the middle of our unit.

So this was in a hallway that patients, family members, staff would walk through.

It was essentially in the heart of our unit.

Our charge nurse desk was behind us.

The supply closet was behind us.

The staff restroom was behind us.

There was a patient's room next to it, a monitoring station to the left around the corner.

Very, very busy, high traffic area.

And so while I'm checking in with my orientee, you know, also in the process of looking for this monkey's medication for the third time.

So I allowed myself to be distracted.

I engaged in behavior that I should not have.

And that was really the beginning of a series of things that started to go wrong.

Choices that didn't really seem like choices at the time, but things that we do that in hindsight, looking back, we should have known better.

So I'm checking in with him, making sure he has these things.

I'm back at this machine.

I'm looking again.

Same story.

I still don't find the medications under her profile anywhere.

So this is the third time I've looked.

I can't find it.

So my obvious choice is that I need to override.

I select the override, which is the fourth option, the stat, CRN, routine, override.

I select override.

The next screen that prompts itself is to answer a question about what's the necessity for overriding.

Prior to Epic, we could have entered something manually up to so many characters.

When Epic was launched, we already had the option to choose from a multiple choice list of responses.

Right.

From like a pull-down menu?

Right.

None of which were appropriate.

None of them were going to say, we don't know what's happening.

And the medic, but it's not there for no reason.

So automatically, anything that I select at this point is not going to be truthfully accurate.

It's not going to be the appropriate response.

So it's kind of irrelevant what you pick.

You just pick the first one and you move forward because we need to move the process along.

This is only another thing that we have to work around to get to what I'm trying to get to, which is the drug that I need for the patient.

So I feel like the first thing, which I believe might have been something like the physician is present at the bedside or something.

The next thing that we are able to do is to search for the drug that you want.

Now, best practices have recommended that things be different.

But at the time, it was set up so that you could toggle between generic drugs and brand name drugs.

This continues to be an argument whether you should separate them or just put them all under one search field.

But I think best practices have decided to put them all under one search field.

But at the time, you could toggle between them by selecting a little button on the bottom of the screen.

Profile automatically goes to generic by default.

So typing in the name of this drug that I need by the brand name, which is Versed.

And you can type those six letters in with your left hand, call one word, Versed.

Obviously, had I paid closer attention, I would have realized that by searching under generic names, I'm not going to find a brand name drug.

I'm not going to get the correct thing.

However, as I'm typing this in, there's a drug, you know, an option to select something on the other side of the screen.

It's given me a response.

And, you know, I've typed in B-E-R-S-E-C.

Not just B-E.

I don't know where that keeps coming from.

I do, but we're not going to go there.

I typed in the entire word person.

An option pops up.

I've told the machine what I want.

So I clicked that option.

I did not read it closely.

I'm assuming that it knows what I have told it that I want and that it would only be able to give me what I have told it that I want.

At that point, I select this medication and a drawer opens automatically and then a little pocket inside of that with a plastic clear lid pops up.

You grab the medication that you want out of there.

I close both things.

I walk out.

There was never any type of stop that would have required you to say.

Yeah, confirmation.

Verify.

Yeah.

Right.

With high-risk drugs, often you'll get stop warning.

You may get a requirement for a second person to come and enter their bio ID, like their fingerprint or their PIN number to confirm that two people have looked.

Said, okay, this is a high-risk drug, this is what you're getting.

There might have been a count, like let's say count the number of vials that are there before or after you pulled this one that you're grabbing, a series of things that you could expect.

So particularly with the type of drug that I accidentally got, there was always a warning that said, hey, you know, hey, person, this is a paralytic agent.

You have to be prepared to breathe mechanically for this patient, the physician, and all the intubation materials must be ready and present at the bedside before administering this drug.

Before that and after, I have never pulled a paralytic agent and not seen that warning that you have to physically acknowledge.

You have to say, okay.

And oftentimes, there is another person that must come and stand their fingerprint or put in their password so that you can pull that drug because it comes with such a high risk or with nothing.

Another great thing about electronic health records and systems like Epic is that they do track everything.

So if there had been any version of a warning that had been present or something that I've had to acknowledge, it would have been there.

Yeah.

And it wasn't.

You know, the DA has all the evidence to prove that there wasn't a warning there.

So at this point, I've grabbed this medication.

I believe that it's what I've needed.

Confirmation bias in my head that I've told it.

I want those dead.

How could it give me anything else?

A lot of out of the machine, we go downstairs to find our patient.

It's probably 10 minutes or so.

So at this point, 25 roughly minutes have passed since I've gotten the phone call asking me to do this task.

I don't know where cut skin is.

We have to get some direction.

I find it.

I find our patient.

I introduce myself to her.

I use her barcode sticky thing on the back of my badge to make sure that it matches her armband and see if she's calling me she is.

And I tell her I'm there to give her some medication for her anxiety.

I look around in some of the empty rooms to use a barcode scanner to document that I'm going to administer this particular vial of drugs to this particular patient by scanning for a wristband.

There isn't any such device.

After a few moments of looking around, a young woman comes from an opposite set of double doors from which I had entered, and she confirms that they do not have barcode scanning technology for medication administration in the radiology department.

They're still documented on paper.

So I have to move forward in this process without engaging in that first.

So I said, okay, I'll have to give it a medication.

And then I will have to go back.

And in retrospect, I will have to document this drug later when all of those things are present.

At this point, I grabbed this vial out of this bag in my pocket.

And I can see that there's something different about this vial.

So again, for context, Versed or Medagalan is a liquid, always in a liquid form.

It comes in an amber colored vial because it needs to be protected from light, from UV rays.

And it has an orange-yellow colored plastic cap over the top, which you have to pop off before you get the needle into it for all the fluid.

But this vial that I had in my hand was a clear vial with white powder and a gray plastic cap.

This was clearly something different that I wasn't expecting.

And again, for more context, I'll kind of provide you why that wasn't exceptionally out of the ordinary and why I continued after that.

So I believe it was September timeframe.

Don't quote me on this.

But fall of 2017, Hurricane Maria hit the island of Puerto Rico.

And you can do your research on this, but anyone who works in hospitals, especially in pharmacy and large hospitals, remembers that it wiped out the islands of Puerto Rico.

3,500 people were killed.

Infraestructures destroyed.

Some of those infrastructures were drug manufacturing facilities that provided lots of medications to hospitals in the continental United States.

And so after that, we started seeing all kinds of medications coming through in different forms.

Things that we would have...

Remix in IV fluid bags like antibiotics, we were now having to pull from these sort of glass piles of powder and reconstitute them with liquid and give them that way or put that liquid into an IV bag.

We were reconstituting steroids, which again would have been in liquid form.

Lots of things were changing.

And if you can imagine for a moment, a hospital the size of Vanderbilt and the amount of medications that we would go through given the highly specialized levels of care that we provided, that would have been a lot of medication changes.

Certainly not one that you could have stayed on top of on a daily basis and known.

Hey, you know, just one out of hundreds of units, you're going to start seeing these medications change today because we're going to use them at different rates than other units.

are.

Does that make sense?

Yeah, completely.

It's not really something you could continuously say, hey, we're going to see these drug changes today because other units may not use those drug changes at all.

We may use them more commonly.

How on earth do you distribute that information?

So it's something we had been working through for probably three months at least prior to that.

You might open up a pocket and see two very different looking things, two different brands, very different looking things.

Not uncommon so you know i'm here i'm off of my unit i'm out of i'm out of my normal area i'm in an area i've never been in before i'm encountering this thing that it looks different and immediately i'm trying to rationalize what is it about this that you know is this this must be another one of those situations where i didn't notice it at the time when i grabbed the medication out of the cabinet but.

Something's different here.

We must be reconstituting this dedication now.

I glanced very, very quickly at the name on the vial.

You know, the truth is, you know, I didn't read it carefully.

And then in the beginning, all I said was I didn't read it.

Because, you know, in my mind, if I had actually stopped to fully read it, I would have read that it did not actually say for said.

I glanced quickly.

I thought it said Burstead.

I didn't pause fully to read the actual name of the drug.

The first couple of characters matched up.

I'm making assumptions based off of the last three months of changing medications throughout our facility, and I looked at the reconstitution rate on the other side of the vial.

I put the fluid in that I needed to reconstitute it.

I gave her one milligram of the drug, which I believe was one milligram of her dead.

The nuclear med tech was still there waiting for me to finish giving her this medication.

At that point, when I was done, she was ready to take the patient, I assumed, back directly into the test scan area.

And she didn't mention any concerns about staying with the patient or monitoring her because of this type of drug that she'd been given.

However, she had mentioned that on the phone to the patient, finding a nurse, unbeknownst to me.

It wasn't until many years later when we were sitting in court during her testimony that she stated she didn't say anything to me because she believed this young man, this orientee.

This new nurse that was following me.

Right.

She believed that that was her primary nurse that she'd been speaking to on the phone.

She was also a young man who was 20.

She was confused about why I was there and why he was with me and not doing anything, but she never, she never brought that up, you know, in the moment.

She never, and there were two of us there, you know, she never asked one of us to stay.

Had I had any inclination, had I picked up a vibe that something didn't feel right, I would have stayed.

The next thing we were doing was not anything urgent that I could not have stayed there.

You know, my job as a help all is to do what I needed to do at that moment.

So my time was free to do what I needed to do.

I absolutely could have stayed.

I really hate that we didn't, that I didn't pick up on it.

Something was wrong, that she was confused.

She never said anything.

She took the patient one way.

So my oriental and I left, we went to the emergency department.

That patient was out of the unit for a CT scan.

I left my number we went back upstairs so at this point maybe 10 minutes will pass maybe 15 I'm back upstairs I leave him with another nurse to do something or take a break and I go and I find Miss Murphy's primary nurse and I my goal was to let him know that I've given her the medication, which I did and then to leave this bag of medication with him so that I'm not walking around in multiple other patient rooms with a bag of reconstituted medication.

An IV sedation medication particularly, in my pocket.

I can leave it with him.

He has a locked cabinet.

He can let me know when the patient returns.

And at that point, when the patient returns, I will have all of the things that I need to create documentation of the administration of this drug.

And those things are myself as the nurse, a computer with a barcode scanner, the patient with this arm band that she's wearing which is specific barcodes the computer notes and then the drug itself I need it all four of those things I'm telling him this I'm saying let me know when you get when she gets back and I'll come.

That point, the rapid response is called for a patient and PET scan.

We don't know for sure that it's our patient.

We can't get an answer.

So long story short, my charge nurse and I walked downstairs all the way back down six floors through the emergency department through radiology to PET scan to find out if this was our patient or not.

It was.

At that point, the code team was there.

We were ready to, she was ready to move out of radiology into a critical care bed.

So we transported her back upstairs.

We spent the next hour in her room doing pretty typical post resuscitation things, which would have been putting her on a mechanical ventilator, doing x-rays to make sure everything was placed right, swallowing blood work to see if there were any abnormalities that we could identify.

We put in bigger forms of IV access, so that's called a central line.

The first one of those failed, so we had to put in a second one.

These are all sterile procedures so far.

And then an arterial line, which would give us a very, very, very accurate blood pressure reading, which was a concern because her blood pressure would have been directly related to her admission diagnosis, which was a bleed in her brain.

And the concern might have been that she has had a working bleed, what was the floor pressure doing, was it a stroke, all kinds of things.

So we're doing all of this.

It takes about an hour.

Again, I'm the help ball.

My role is to be helpful when things like are happening.

So I'm in the room the entire time we're doing this.

And I'm leaving to go spend some labs down stairs.

And at this point, because she's now a critical care patient, she's been placed in a different room with a nurse who's taking care of critical patients that day, ICU level care patients.

So she doesn't have the same nurse that she had before this.

He approaches me and he says, hey, is this what you give the patient?

And he holds up this clear lab bag that I had written the order on and put the vial of medication back into.

And I looked at it and I said, yes.

And that's when he lets me know, hey, this isn't, this isn't so sad.

It's becuronium, which I know that doesn't mean a lot to you, but in health care, you know, we know that that's a bad drug, Todd.

These are the kinds of medications that you give people.

When I say it paralyzes you, it paralyzes you, but it doesn't sedate you.

Wow.

You're fully conscious.

You just can't do anything about it.

Wow.

You are there, aware of what is happening around you, and you slowly lose your ability to move all of your muscles.

It's a neuromuscular blockade, so it blocks the communication between your nerves and your muscles, which means that you cannot move.

The communication is stopped.

It doesn't do anything else.

Your mind is there.

you can hear you can't see because your eyes are probably going to be closed because you can't open your eyelids you can feel you can't do anything about it you can't respond and eventually you can't breathe, because your diaphragm is a muscle that needs to move and wants you to pull air into your lungs, eventually you're going to slip into consciousness, unconsciousness and that amount of time can vary depending on you know how much of the drug.

You got from Ms.

Murphy, it was a fairly small dose, but we're also talking about a patient in her 70s who already had neurological impairments and other comorbidities.

So a small dose, even if it absolutely had been lethal in her case, and it was.

At this point, I'm aware.

Okay, this is a bad situation.

We have a medication error on our hands, and I need to let people know.

So I have him give this medication to our church, tell her what happened, And I go back into the ring and I inform our critical care team, an anesthesiologist, a resident, and two acute care nurse practitioners.

And I think the patient's primary nurse at that time was in line.

I told them at some point over the past hour, hey, guys, I gave them an order and they first said when she was downstairs, so just know if you're looking through her medication record or her EHR, that you're not going to see it there because I couldn't document it.

But it is there.

She bought a milligram of Versed.

I wanted them to know that.

Of course, now I have to tell them, hey, that milligram of Versed that I give her, it wasn't Versed.

It was Becky Williams.

The room was very quiet.

One of the nurse practitioners, she just said, I'm so sorry.

We knew that this was a bad situation.

At that point, I excused myself, I gave my electronic devices to the charge nurse, and left.

So the amazing part of any event is what we can learn from it.

And there's so much in this event that we can learn from.

There's so much interesting and quite remarkable factors that led up to the environment, which allowed the conditions for this failure to happen to happen.

And hearing the story from Redonda, I think is really important.

Next week, let's hear what Redonda has learned from it.

Learn something new every single day.

Have as much fun as you possibly can.

Be good to each other.

Be kind to each other.

and for goodness sakes, be safe.

See you next week.

Music.