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Another Tragedy at Vanderbilt

Nurses   (7,237 Views 161 Comments)
by Nurse Beth Nurse Beth, MSN (Advice Column) Writer Innovator Expert

Nurse Beth has 30 years experience as a MSN and works as a Nursing Professional Development Specialist.

14 Followers; 88 Articles; 226,260 Visitors; 1,755 Posts

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Vanderbilt is having a rough patch. First the lethal Vecuronium error and now a "never event".

A woman at Vanderbilt undergoing kidney surgery suffered a wrong-site surgery to her kidney- a "never event". She filed a 25 million dollar lawsuit due to extensive damage and is now dependent on dialysis. Neither here nor there, but one news report said the woman was a certified nursing assistant (CNA).

In the first case, the RN was arrested and charged with reckless homicide. Should the surgeon likewise be arrested and face charges? 

 

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0.9%NormalSarah is a ADN, RN and works as a MICU RN.

342 Visitors; 78 Posts

What about the time out? Wasn’t this a breakdown of the whole team and not just the surgeon? This is a serious question, I do not know. Maybe not an apples-to-apples comparison but I’m really not sure, and I look forward to seeing other nurses’ perspectives on this.

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Newgradnurse17 has 2 years experience as a BSN.

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Wait! The RN was arrested but no one else on the team? Even the surgeon who actually did this? At the end of the day it’s there pt, they are the one doing the surgery, it’s there responsibility. 

Pinning this all on one RN is horrific. 

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Sour Lemon has 9 years experience.

2 Followers; 29,023 Visitors; 4,103 Posts

33 minutes ago, Newgradnurse17 said:

Wait! The RN was arrested but no one else on the team? Even the surgeon who actually did this? At the end of the day it’s there pt, they are the one doing the surgery, it’s there responsibility. 

Pinning this all on one RN is horrific. 

She's talking about two different cases. The surgical RN was not arrested.

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Sour Lemon has 9 years experience.

2 Followers; 29,023 Visitors; 4,103 Posts

2 hours ago, 0.9%NormalSarah said:

What about the time out? Wasn’t this a breakdown of the whole team and not just the surgeon? This is a serious question, I do not know. Maybe not an apples-to-apples comparison but I’m really not sure, and I look forward to seeing other nurses’ perspectives on this.

Same here. It's sad that no one noticed and I wonder if time out wasn't taken as seriously because it was "just" a stent. I'm also curious as to what sort of damage a stent can do, because I (obviously) don't know much about kidney stents and think of them as  "helpful" or corrective.
How do they harm? I'm also very interested in what others with more knowledge have to say.

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Luchador has 5 years experience as a CNA, EMT-B.

1,303 Visitors; 197 Posts

Wow, Vanderbilt seems top notch.  When you have numerous "never events" should we stop calling them "never" and just start saying, "meh. . . that's Vanderbilt."

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MunoRN has 10 years experience and works as a Critical Care.

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There was also a new lawsuit a few weeks ago against Vanderbilt for wrongful death due to a stroke resulting from placing a central line in the carotid artery instead of the jugular, this was an unsupervised resident physician placing the line. 

Like the Vecuronium incident, this wasn't helped by excessive diagnostics/treatment, the central line was placed because Vasopressin was ordered, even though the patient's BP when the Vaso was ordered was 131/77 and the patient had never been hypotensive.

https://www.wsmv.com/news/family-sues-vanderbilt-university-medical-center-for-wrongful-death/article_4a38adaa-3eb5-11e9-959d-ff3ace513708.html

 

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10,264 Visitors; 1,380 Posts

Yeah, this is why I was not a fan of the nurse charges. Now every screw up can be criminal. 

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3,583 Visitors; 234 Posts

Did the surgical team and the surgeon PURPOSEFULLY decide not to do a time out, and ignore all other checks and safety measures that were in place to prevent this sort of "event"? Did he just look at the patient and the chart and go "Forget the bad kidney, lets do the good one, I'm sure it will be fine?" 

The RN that was arrested and charged was so because she made SEVERAL purposeful errors and used extremely poor judgement calls. She ignored a multitude of safety measures, including the simplest, most basic prevention in medication error; looking at the medication label. A woman CONSCIOUSLY suffocated to death because of this woman's lack of judgement and neglect. What she did was not accidental. It was purposeful. She didn't intend for it to happen, but it was purposeful nevertheless. And all she had to do was LOOK at the label (for more than reading the instructions).  

So, if the surgeon acted in gross negligence like the nurse did? Sure, charge him with "something". 

I also think attempting to compared what the RN did to "lesser" incidents of negligence, or even actual accidental errors, takes away from the grievous nature of what she did. 

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Daisy4RN has 20 years experience.

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My first thought was: Wow Vanderbilt has some serious issues (which of course they do), my second though was that this is probably more widespread than we know (although I hope I am wrong!). I have worked in Univ. teaching hospitals and would tend to agree that Interns and Residents need more oversite. 

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Daisy4RN has 20 years experience.

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1 minute ago, Miss.LeoRN said:

Did the surgical team and the surgeon PURPOSEFULLY decide not to do a time out, and ignore all other checks and safety measures that were in place to prevent this sort of "event"? 

My guess would be that everyone was working on auto-pitot because of all the "necessary" paperwork/checklists etc.

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1 Follower; 11,704 Visitors; 1,302 Posts

How can any coherent statement on the OP be made with no information provided at all?

Is this just a way to cheap shot Vandy?

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