Rainbow I may be straight but I don’t hate shirt

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I keep going back and Rainbow I may be straight but I don’t hate shirt. We all make mistakes and some of those mistakes kill. Sometimes even when medical providers do their due diligence a mistake reaches a patient. Hopefully, we look at what allowed the mistake to happen, educate, change policies and move on. In this case, it goes beyond a mistake. We are looking at an individual who over the road a medication she had no knowledge of. When you override you need to be beyond meticulous. We all know the details at this point I believe. She puts in the first letters of the drug. Even under brand versed would have been on that screen but instead of reading the drug names she chose the one on top. Obviously, she didn’t read it or thought vecuronium and versed were the same thing.

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She then bypasses every safeguard placed on this medication including the Rainbow I may be straight but I don’t hate shirt. The ring under the cap that said paralytic. The bottle label that says paralytic. She reconstituted what in her mind was versed. Again shows she has no knowledge of what she was giving. She admits to not looking at the label of the medication. She then proceeds to administer the medication. She failed to monitor the patient after administration which she should have done. She failed to place the patient on a monitor which would have alerted staff to a problem. She left. She didn’t hand off to another nurse to monitor the patient. She left the patient alert, paralyzed and suffocating slowly to death.