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?
The onset of Vecuronium is pretty fast. Certainly well under a minute. She gave the Versed rapid push and booked too quickly to see what was happening. Had she administered it more slowly or actually looked at the patient I would hope she would have noticed the lack of respirations.
I’m a little confused by your use of the term “legal” when it comes to nursing SOP. For example the 5 rights of med administration are not legislated but they are the basis for safe medication practice throughout the US and I imagine the rest of the developed world. It is not illegal to omit doing them but they are the usual and customary process we follow and to not do so is reckless. Each BON has rules for the practice for nurses in their own state. Those aren’t legislated either. They are the rules of licensure but not necessarily the law. However, not following the usual and customary practices can get you in trouble with the law if the patient is harmed or dies. And so it should.
As far as monitoring a patient after an IV push med, you keep using terms like “continuous monitoring” which clouds the picture. I’m talking about a few minutes of observation not ongoing monitoring in the strictest sense. Adverse reactions generally will occur very rapidly after IV push administration. We reassess later for efficacy not reactions. This is standard of practice and I don’t really care how many nurses aren’t doing it. It’s just plain crappy nursing practice. RV displayed multiple examples of poor practice in just this one instance and look what happened to a vulnerable patient. Sloppy practice begets more sloppy practice and the patients are the ones who pay.
I don’t really subscribe to the notion that we are all at risk for criminal charges for even the simplest of mistakes. It just hasn’t happened despite precedent being set over 20 years ago for nurses being criminally charged for patient deaths related to medication mishaps. The source stating the reason for the charges against RV being isolated to the Accudose override is the news media and I believe the real truth is that the prosecutor looked at the entire series of events which were absolutely hair raising.
The source that the override of the medication was the basis of the charges comes from the DA's office, specifically their spokesman Steve Hayslip. If a DA takes that to mean she took a crowbar to the medication cabinet or somehow hacked it's software to obtain the med, then that could potentially justify the charge, but it doesn't appear that's what happened.
There's no arguing that this was all around bad nursing, as well as multiple systemic failures separate from RVs actions, but that isn't what defines reckless endangerment or reckless homicide. It's the actions themselves that define 'reckless', not the outcome of those actions, any action that can be correctly defined as worthy of reckless homicide charges would also justify reckless endangerment charges if there is no harm to a patient, so then it comes down to which actions would support that.
To qualify as 'reckless' act have to be more than not-unheard-of errors or bad judgement. To use the example of driving a car rather than providing nursing care, if you cause an accident going 5 miles over the speed limit, that's not subject to 'reckless endangerment/homicide' charges, since even though it's bad driving and known to cause accidents, it's not wildly outside the range of driving habits. Typically, to justify a 'reckless' charge related to driving you would have to be going at least 25-30 over the speed limit.
So then the question is which one of her acts grossly exceeds the range of bad habits or judgement that regularly exists. Override is often a function that is expected to be used, particularly in critical care or procedural areas. Pulling the wrong med is far from unheard of, as is administering the wrong med.
The peak effect of midazolam is 5-10 minutes, and while it's certainly ideal to monitor a patient for some time after it's administration, ideal and reality are two different things, and typically 1mg of midazolam in an adult doesn't rise to the level of that sort of attention. There was clearly an lapse in reassessment monitoring, which falls to the primary nurse who delegated the task of giving a med to RV, not the overall care, typically in this scenario that would fall to the imaging nurse.
I am just a humble RN student, but pushing a med without even looking at what the hell you are pushing is incomprehensible.
That's the right way to look at it and hopefully that never changes in your practice, but in reality giving the wrong medication is far more common an occurrence than it should be. This could be improved with both better compliance with this basic rule, and systemic safeguards.
That's the right way to look at it and hopefully that never changes in your practice, but in reality giving the wrong medication is far more common an occurrence than it should be.
Oh, I know. Our professors have done an excellent job of scaring the s*%t out of us by assigning some case studies and such.
Last semester during a sim we had to pull meds from a Pyxs. They were devious. We had orders to give meds the pt was allergic to and one of the compartments was stocked with a wrong med (but spelled similar).
I still maintain RV is being charged because the BON failed to do a damn thing-- not even requiring education. Ridiculous.
Oh, I know. Our professors have done an excellent job of scaring the s*%t out of us by assigning some case studies and such.
Last semester during a sim we had to pull meds from a Pyxs. They were devious. We had orders to give meds the pt was allergic to and one of the compartments was stocked with a wrong med (but spelled similar).
I still maintain RV is being charged because the BON failed to do a damn thing-- not even requiring education. Ridiculous.
That may well be part of it, but I don's really think requiring education at this point has much to offer, there are probably few nurses more aware of the importance of medication safety than RV is right now.
Specializes in Mental Health, Gerontology, Palliative.
On 3/25/2019 at 7:39 AM, Luchador said:
When I had a knee operation the surgeon signed the correct knee with a big sharpie and then had a witness as I signed the correct knee. Then they gave me ketamine and it was amazing.
"Never event" indeed. Buy a damn sharpie.
I had ketamine once.
Woke up in PACU thinking i was an 80 year old mexican woman on my way to market, being accosted by red coat soilders
if the regulatory body would do there job criminal charges should not be needed
Please expand upon this more, what regulatory bodies are you referring to and what interventions should they have taken? Are you thinking a harder NCLEX? Or maybe license renewal through routine NCLEX testing every 5-10 years?
Please expand upon this more, what regulatory bodies are you referring to and what interventions should they have taken? Are you thinking a harder NCLEX? Or maybe license renewal through routine NCLEX testing every 5-10 years?
They are referring to the TN BON having reviewed the RV situation and declined to discipline the license.
They are referring to the TN BON having reviewed the RV situation and declined to discipline the license.
Ah, still doesn't make sense to me though.
From my understanding there were already multiple investigations undergoing at the time of the DoH letter that notified her that there were not going to take further action, which makes sense.
Why investigate something when there are higher level investigations (including a criminal investigation by the TBI) already ongoing? Any investigation by the DoH would appear silly and incompetent against a formal criminal investigation. Whatever the DoH ruled would have had no bearing on the ongoing criminal investigation.
Once the other investigations completed then the DoH can swoop in and take action.
The DoH did not find her faultless, they just stated they were not taking action at that time based upon consultant and attorney recommendation.
MunoRN, RN
8,058 Posts
The source that the override of the medication was the basis of the charges comes from the DA's office, specifically their spokesman Steve Hayslip. If a DA takes that to mean she took a crowbar to the medication cabinet or somehow hacked it's software to obtain the med, then that could potentially justify the charge, but it doesn't appear that's what happened.
There's no arguing that this was all around bad nursing, as well as multiple systemic failures separate from RVs actions, but that isn't what defines reckless endangerment or reckless homicide. It's the actions themselves that define 'reckless', not the outcome of those actions, any action that can be correctly defined as worthy of reckless homicide charges would also justify reckless endangerment charges if there is no harm to a patient, so then it comes down to which actions would support that.
To qualify as 'reckless' act have to be more than not-unheard-of errors or bad judgement. To use the example of driving a car rather than providing nursing care, if you cause an accident going 5 miles over the speed limit, that's not subject to 'reckless endangerment/homicide' charges, since even though it's bad driving and known to cause accidents, it's not wildly outside the range of driving habits. Typically, to justify a 'reckless' charge related to driving you would have to be going at least 25-30 over the speed limit.
So then the question is which one of her acts grossly exceeds the range of bad habits or judgement that regularly exists. Override is often a function that is expected to be used, particularly in critical care or procedural areas. Pulling the wrong med is far from unheard of, as is administering the wrong med.
The peak effect of midazolam is 5-10 minutes, and while it's certainly ideal to monitor a patient for some time after it's administration, ideal and reality are two different things, and typically 1mg of midazolam in an adult doesn't rise to the level of that sort of attention. There was clearly an lapse in reassessment monitoring, which falls to the primary nurse who delegated the task of giving a med to RV, not the overall care, typically in this scenario that would fall to the imaging nurse.