Sally, a licensed nurse, has been working in the Intensive Rehabilitation Unit of a local community hospital for the past 6 months. She graduated in the top five of her nursing about two years ago. She normally works 7:00 AM to 7:00 PM three days a week. About a month ago, the nurse manager asked Sally if she would be willing to work an extra shift on 11:00 PM - 7:00 AM the following Sunday. Sally agreed.

She was assigned to a 21 year old mechanically ventilated patient who was admitted to the unit after sustaining multiple injuries from a motor vehicle accident five days before. Since admission his vital signs improved and stabilized, his Level of Consciousness, although labile was improving, and he was beginning to initiate and maintain spontaneous breaths at a vital capacity of greater than 500 mL.

On her first round at about midnight, Sally noted that the patient was resting comfortable, his monitor showed all vital signs are within normal limited, IV fluids were infusing, urine output was clear and in normal amounts. At 2:00 AM, the patient monitor alarms rang and when Sally responded she found the patient attempting to extubate himself. With the assistance of some of the other nurses, Sally was able to medically restrain (according to approved facility policy) the patient's upper limbs and to administer 1.0 milligrams of IV Ativan.

At 4:00 AM when the Medical Intern was beginning the morning work-up, Sally informed her of the events of 2:00 AM. The Medical Intern recommended and wrote physician orders to check the Arterial Blood Gases and if the results are within normal limits, then she, in consultation with the respiratory therapist, could wean the patient off the ventilator to extubation.

At 4:30 AM, Sally and the respiratory therapist began the weaning process. By 6:00 AM, the patient was breathing spontaneously without the assistance of the ventilator. At 6:30 AM the patient began to demonstrate symptoms of mild restlessness and brief, but periodic drops in his oxygen saturation with corresponding increases in his heart rate. Because the monitor alarms were ringing frequently, Sally decided that the patient's behavior was a result of his improving condition and his anticipation for the proposed medical plan to advance his rehabilitation plan.

Sally reread the patient's medication administration record and determined that lorazepam (Ativan) was ordered as "every six hours" and since he last received it at 2:00 AM, it wasn't possible to administer it. The patient also had orders for morphine sulfate, but Sally's assessment did not indicate any signs or symptoms of pain. The last PRN order for the patient was for "vecuronium 1 milligram IV for agitation every 15 minutes times four doses". Sally drew up and administered by IV, 1 milligram of vecuronium at 6:45 AM and repeated the dose at 7:00 AM. While doing report with the oncoming day shift nurse, it was discovered that the patient was in full respiratory arrest.

Resuscitative efforts failed and the patient was pronounced dead at 8:20 AM by the medical intern. Upon review of the patient's medical record it was discovered that Sally had administered 2 doses of a paralytic agent and upon autopsy it was confirmed that the respiratory arrest was directly related to the vecuronium present in the patient's system.

Sally was suspended with pay during the internal investigation. The facts uncovered during the investigation was that Sally admitted to the nurse manager that she has not ever seen the medication, did not know what kind of medication it was, how to use it or any specific information about the drug including the hospital policy that clearly stated vecuronium was to be administered only in those patient who are intubated. When questioned why she would give a drug that she knew nothing about, she responded that it was late in the shift; she felt hurried, and thought it would be safe.

The Board of Registration in Nursing opened a complaint and after a full investigation of the evidenced sanctioned Sally with a 1-Year Probation.

Case Study Questions:

  1. What Standards of Conduct at 244 CMR 9.03 were violated?
  2. How could Sally have avoided violating these standards?
  3. What are the professional standards of care that were violated?

This information is provided by the Division of Health Professions Licensure within the Department of Public Health.