Patient had femoral central line s/p cardiac procedure, which was infusing vasopressors, which the nurse thought they had clamped prior to the patient standing at the side of the bed. Instead, because of what was described as a “perfect storm” of circumstances leading up to the event, the patient received a bolus of the vasopressor and went unresponsive and pulseless shortly after standing as a result of the bolus. The patient was revived and walked out of the hospital two days later.
An investigation ensued, and the nurse was found responsible for the incident, but not relived of their duty. The manager indicated that a series of events occurred and cascaded into a perfect scenario for the incident (nurse practice, medication, new orders) ; what the manager called “a perfect storm”.
Lesson: disconnect discontinued medications from the patient when they’re ordered to be stopped, rather than clamping them.
Oh gosh, you should read “Small Great Things” by Jodi Picoult
