Outcome Bias, Near Misses, and Two Vials of Vecuronium

tl;dr: A nurse nearly administered vecuronium instead of vancomycin but caught the error before it reached the patient. The near miss shows how outcome bias and underreporting distort safety data: when leaders see only errors that cause harm, they may blame individuals instead of recognizing system hazards that other nurses encountered–and stopped–without anyone ever learning from them.

In a busy emergency department in the early 2000s, nurses were mixing some of their own medications. One nurse reached for what she believed was a gram of vancomycin and added 10 milliliters of diluent.

Something seemed off.

She couldn't say what. Even twenty years later, she still couldn't say exactly what made her stop.

She realized the bottle was vecuronium. A paralytic. As she described it, the vecuronium bottle was the same size, had the same color label, and was mixed in with eight or ten bottles of dry vancomycin.

She believed she was about fifteen seconds from killing somebody. She wrote later that there had been many system failures, yet it still would have been a dead patient with her name on it.

Someone replied, “That's why you still have your license and RaDonda doesn't.”

She thanked them for saying that. Then she added that it was as much luck as skill. A busier night, or one interruption at the wrong moment, might have led to a very different outcome.

This is the fourth post I've written from a thread on the r/nursing subreddit where a nurse asked about the worst medication error people had seen. I can't verify the stories. They're anonymous, some are secondhand, and none come with an investigation attached.

I'm not using the thread as proof of what happened. I'm using it as a window into how nurses talk with each other about errors, near misses, blame, and reporting.

I should also be clear: I'm an industrial engineer, not a clinician. I've spent more than twenty years working with hospitals, but I've never given a medication. I'm looking at this through a systems, safety, and leadership lens.

Fifteen Seconds Apart

RaDonda Vaught was a nurse at Vanderbilt. In 2017, she pulled vecuronium from a medication cabinet, believing it was Versed, and administered it to a patient named Charlene Murphey, who died. Vaught was criminally prosecuted and convicted, and her name became widely known in nursing.

The nurse in the thread picked up vecuronium from a group of vancomycin bottles, believing it was vancomycin, and stopped.

Same drug. A related kind of hazard: a paralytic appearing where a nurse expected a non-paralyzing medication.

That does not mean the two nurses followed the same sequence of actions or made identical choices. They did not. But one event reached the patient and entered the legal and public record. The other ended with a pause and survived as an anonymous story on Reddit.

One of the practical differences may have been fifteen seconds and one uninterrupted thought.

A Near Miss Is Not a Safe System

Here's the question I kept coming back to about the vecuronium near miss:

Did she report it inside the hospital?

Think about what might happen if she does. The patient is fine. There is no rapid response, no family to call, and no risk manager waiting. Somebody says thank goodness. Perhaps somebody says, “Good catch.”

And that may be the end of it.

I've written about this before. When a nurse catches an error before it reaches a patient, we might be tempted to say, “The system worked.”

But the system put the vecuronium in with the vancomycin.

The nurse caught it.

She was the last barrier between that bottle and a patient. That's not a strong system. That's a weak system that got lucky.

That near miss might have been one of the most valuable learning opportunities in the department that year. But if it wasn't reported, it generated no incident report, no review, no countermeasure, and no organizational learning. It became a scary memory, and the shift continued.

Our mental picture of “the kind of nurse who gives a patient a paralytic by mistake” is therefore built mostly from cases where the error reached the patient.

That's what makes the Reddit thread useful. Harm events and near misses sit side by side, told by the same people in the same kind of language.

In most organizations, they don't get filed together. Often, the near misses don't get filed at all.

What the Error Data Leaves Out

What does your organization's record of medication errors actually show?

Too often, it shows the Reddit thread with most of the near misses deleted.

When a near miss goes unreported, the nurse who caught the error may avoid scrutiny or blame. But the organization also loses the record, the learning, and the opportunity to improve.

The data leaders review is therefore skewed toward events that caused harm.

If the only vecuronium events leaders see are the ones in which a patient was harmed, it becomes easier to conclude, “That must have been a bad nurse.”

But that conclusion may come from bad data, not better judgment. The data set is missing the nurses who encountered a similar hazard and caught it in time.

The stranger reading Reddit and the executive reading a quality report may have the same problem: they can see the nurse involved in the harm event, but they can't see the nurse who stopped a related error before it reached the patient.

We see the same pattern in sports. After the Seahawks lost Super Bowl XLIX by throwing an interception at the goal line instead of handing the ball to Marshawn Lynch, the play call was widely mocked as obviously stupid. Had the pass been completed, many people would have called it bold, unexpected, and brilliant.

The play call does not become wiser or dumber after the ball is caught or intercepted. But our judgment of it often does.

That's outcome bias. We judge the quality of a decision by the result we can see, while giving too little weight to the information, probabilities, and system conditions that existed at the time.

The Near Misses You Already Have

Public discussion of Vaught's case was understandably dominated by one medication-cabinet override that ended in a patient's death.

Here's the question I can't answer, and I'd like to know if anyone can:

How many other nurses at Vanderbilt used an override that year and retrieved the medication they intended to retrieve?

How many selected the wrong medication and caught the error before administering it?

Somebody could have counted. Those numbers would have mattered, whether they were large or small. I don't know whether the jury was shown that denominator.

In the Reddit thread, three comments appear within a few minutes of each other.

One nurse says she now types “midazolam” into the cabinet instead of “Versed,” because she doesn't want Versed and vecuronium appearing near each other on the screen.

Another says she tells people “not to Vanderbilt” the patient.

Another remembers holding both vials in a nursing school lab and asks how anyone could fail to notice that Versed doesn't need reconstituting.

One changed her own practice. One turned the hospital into a verb. One treated the event as a lesson about the person.

The Data You Already Have

Here's the part I find unexpectedly encouraging.

I don't think the first gap is judgment. It's visibility.

People are making judgments based on the cases they can see. What they usually can't see are the near misses.

Unlike the connector I wrote about last time, which would require suppliers, standards, and years of work, the near misses are already happening.

In your hospital. This week.

Somebody picked up the wrong vial, caught the mistake, set it down, and said nothing. Losing that learning opportunity may feel cost-free in the moment.

It isn't.

You don't have to manufacture near misses. You have to hear about them, learn from them, and act on what they reveal.

That brings this back to the first post in this series. The question is not only what leaders do after someone reports.

The question is what people believe will happen if they report.

In that emergency department, according to the nurse, eight or ten bottles of dry vancomycin were stored together, and one of them was vecuronium. She caught the error on a night that wasn't especially busy, when nobody happened to interrupt her.

She told the story to strangers on the internet twenty years later.

I don't know whether she ever told anyone at the hospital.

That's the problem.