A patient is due to have a PET scan but is claustrophobic so the physician orders 2 mg of Versed for anxiety. The nurse then went to fill this prescription from one of the hospital’s electronic prescribing cabinets, which allows staff to search for medicines by name through a computer system.
The nurse could not find the Versed, so the nurse triggered an “override” feature that unlocks more powerful medications.
The nurse then typed the first two letters in the drug’s name – “VE” – into the cabinet computer and selected the first medicine suggested by the machine, not realizing it was vecuronium, not Versed. The nurse then goes and overrides the barcode scanning system and administers the 2 mg of vecuronium.
The patient goes to the radiology department for the PET scan and while there goes into cardiac arrest and dies.