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?
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.
The BON finding was in October, which appears to be long before the criminal charges. According to the BON's letter, they found it "does not merit further action", which would seem different than just deferring action.
Specializes in Mental Health, Gerontology, Palliative.
2 hours ago, Asystole RN said:
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?
Board of nursing
They felt that despite RV bypassing at least 7 medication checks/safety protocols and directly causing the death of a patient there was nothing they needed to do
She should have lost her license at minimum with severe remediation needed if she ever happened to be allowed to practice again
I wasnt a favour of criminal charges until i found out that the regulatory body didnt do a damm thing allowing her to potentially do the same thing again
I think we'd all agree, including the TN BON, that no medication error or other patient safety failure is benign, but at the same time it's not typical to revoke a license for giving the wrong medication.
Come on Muno you know it was way more than just giving the wrong medication.
The outcome was certainly far worse than the typical 'wrong med' medication error, but that's still what it was. Is the error itself different if she had wrongly grabbed famotidine or protonix instead?
The outcome was certainly far worse than the typical 'wrong med' medication error, but that's still what it was. Is the error itself different if she had wrongly grabbed famotidine or protonix instead?
Yes it is very different and no amount of minimizing it is going to change that. Might I add that she also took a verbal from another nurse which is actually illegal. How does that fit into your simple medication error mindset? Do you think her sloppy practice should just get a slap on the wrist and an "oh you naughty girl?"
The BON finding was in October, which appears to be long before the criminal charges. According to the BON's letter, they found it "does not merit further action", which would seem different than just deferring action.
Generally you investigate before filing charges, you know to determine if there is evidence to support charges? Even then it wen to a grand jury to levy charges.
From my understanding the adult protective services investigation started very early along with the CMS investigation. Once adult protective services identified possible issues they contacted TBI.
The DoH always reserves the right to defer action or revisit issues. The fact that an attorney and consultant were used to help determine their ruling tells me that they knew something was happening, which makes sense that the TBI would ping them for information on the case.
The outcome was certainly far worse than the typical 'wrong med' medication error, but that's still what it was. Is the error itself different if she had wrongly grabbed famotidine or protonix instead?
Muno - "All she did was give someone some medication."
Everyone Else - "Yeah but she killed someone through gross negligence!"
Muno - "It's still just medication! If you don't mean to kill someone you get a Mulligan on it. What is negligent homicide anyways?"
Yes it is very different and no amount of minimizing it is going to change that. Might I add that she also took a verbal from another nurse which is actually illegal. How does that fit into your simple medication error mindset? Do you think her sloppy practice should just get a slap on the wrist and an "oh you naughty girl?"
A basic principle of risk mitigation is that there is no such thing as a minor medication error, all medication errors should be seen serious. Viewing this as more major, which then makes other medications minor in relation, is referred to as 'severity bias', which we know only increases the risks of future errors and harm.
The Versed order was entered by a physician, not a nurse.
RV wakes up every morning with one of her first thoughts likely being that she killed someone, and likely a horrible death at that, I don't think it's accurate to describe that as a 'slap on the wrist'.
Generally you investigate before filing charges, you know to determine if there is evidence to support charges? Even then it wen to a grand jury to levy charges.
From my understanding the adult protective services investigation started very early along with the CMS investigation. Once adult protective services identified possible issues they contacted TBI.
The DoH always reserves the right to defer action or revisit issues. The fact that an attorney and consultant were used to help determine their ruling tells me that they knew something was happening, which makes sense that the TBI would ping them for information on the case.
I can't find any record of an APS investigation. The DA's office stated that their decision to investigate and press charges came after reading the CMS report.
Muno - "All she did was give someone some medication."
Everyone Else - "Yeah but she killed someone through gross negligence!"
Muno - "It's still just medication! If you don't mean to kill someone you get a Mulligan on it. What is negligent homicide anyways?"
I'm not clear where I said anything similar to the above, maybe you could point me in the right direction.
Again, I believe it's important to see medication errors as a serious issue to be resolved, seeing a medication error as an isolated issue that's only serious when someone dies disregards the seriousness of the problem every time a med error occurs.
Gross negligence and the resulting reckless homicide charge are clearly defined legal terms, which this case does not meet, which is actually me and the ISMP vs 'everyone else'. I'm fine being on their side on this one (and pretty much everything medication safety related).
Gross negligence and the resulting reckless homicide charge are clearly defined legal terms, which this case does not meet, which is actually me and the ISMP vs 'everyone else'.
Actually, she clearly meets the statute. Typing the first two letters of something into the Pyxs and literally pushing the first thing that opens up (she had to choose to do that) without reading the label (PARALYTIC PARALYTIC PARALYTIC) consciously disregards norms and recklessly put the pt at risk and resulted in the patient's death.
Quote
Terms Used In Tennessee Code 39-13-215. Reckless homicide
Reckless: means that a person acts recklessly with respect to circumstances surrounding the conduct or the result of the conduct when the person is aware of, but consciously disregards a substantial and unjustifiable risk that the circumstances exist or the result will occur.
MunoRN, RN
8,058 Posts
The BON finding was in October, which appears to be long before the criminal charges. According to the BON's letter, they found it "does not merit further action", which would seem different than just deferring action.