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?
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.
It would appear unlikely that she utilized the override function while thinking "this will likely kill someone, but I'm going to do it anyway" which is what the statute requires, it's more likely that she wasn't aware of the harm that was likely to result.
2. We do NOT believe criminal charges are justified.
While our legal system allows for the criminalization of human error even in the absence of any intent to cause harm (see Sidebar 2), ISMP does NOT believe criminal charges are justified in this case. In fact, we find it shameful that a nurse who is already suffering and paying the price for her error is now facing a criminal indictment and possible trial, loss of her nursing license and livelihood, and time in prison. The retrieval of the medication from the ADC via override should NOT be sufficient grounds for the nurse’s criminal indictment, as the District Attorney’s Office suggests, nor should any other “safeguards that were overridden” unless RaDonda was well aware that she was taking a substantial and unjustifiable risk.
The override feature is available in basically every hospital that utilizes ADCs and is a function used every day to obtain specific medications when a delay in treatment could impact patient care. Most often, these are emergent or urgent medications. However, the override feature may also be necessary for other medications and solutions in facilities that do not provide 24-hour pharmacy services. In many hospitals, both midazolam and vecuronium (or another neuromuscular blocker) are available via override for urgent or emergent use when needed. The hospital where RaDonda worked allowed nurses to remove certain medications via override, and it is highly likely that, prior to this event, midazolam and vecuronium had been removed from an ADC via override in this hospital. Also, it is unlikely that nurses, including RaDonda, perceived a significant or unjustifiable risk with obtaining medications via override. In fact, removing certain medications from an ADC via override is an accepted risk in healthcare and one that many practitioners take to provide care to their patients.
Any practitioner who did not consciously disregard what they knew in that moment to be a substantial and unjustifiable risk should not be disciplined, let alone charged with reckless homicide and abuse of an impaired adult.
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'.
Except people who went to school and actually studied the law completely disagree with you.
It would appear unlikely that she utilized the override function while thinking "this will likely kill someone, but I'm going to do it anyway" which is what the statute requires, it's more likely that she wasn't aware of the harm that was likely to result.
No but she was aware that the med she thought she was giving had the potential to kill someone and if she was unfamiliar with it she should not have given it in the first place.
The Versed order was entered by a physician, not a nurse.
RV was notified by a nurse of the need for the medication. She admitted in the CMS report that she did not look at the order. So yes, she took a verbal. This becomes obvious as the order stated to give 1mg, monitor effect and repeat with an additional 1mg if needed but RV couldn’t remember how much she gave and the syringes weren’t marked.
It would appear unlikely that she utilized the override function while thinking "this will likely kill someone, but I'm going to do it anyway" which is what the statute requires, it's more likely that she wasn't aware of the harm that was likely to result.
I'll give you the statute again. Can you cite where intent to kill is required? She choose to type in two letters and push the first thing that popped up. That was a choice. She didn't mistake a med with a similar name, she choose to over-ride and push the first medicine that opened. That was reckless disregard for norms.
You should play a game the next time you are at work. Go to the Pyxs, over-ride it and type in various first two letters--- see if it will kill a person. Maybe start with "Ca." Who knows?!
Here is the statute, show me where intent to kill is in the statute
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.
Specializes in Mental Health, Gerontology, Palliative.
6 hours ago, MunoRN said:
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.
When a patient dies, it damm well should be. And not just dies, but spends their final moments gasping for air, fully conscious and aware. Lets not forget that bit
in my country. Let say if a nurse gave paracetamol 1000mg instead of 500mg they would get a smack on the wrist from their employer. If a nurse gave a medication and bypassed as many safety checks as RV did that resulted in the horrific death of a patient she would have lost her registration at mimimum and had to pay a hefty fine as well as major remediation before being allowed to reregister
Except people who went to school and actually studied the law completely disagree with you.
There's been a lot of discussion among legal experts about the basis of the charges brought, and I actually haven't seen any who agree with the charges, maybe you could direct me to what you're referring to.
The DA doesn't appear to disagree with the criteria for "reckless", but rather are under the impression that using the override function on an ADC is something that is never done as a part of regular practice.
No but she was aware that the med she thought she was giving had the potential to kill someone and if she was unfamiliar with it she should not have given it in the first place.
1mg of midazolam doesn't have a significant likelihood of resulting in death.
RV was notified by a nurse of the need for the medication. She admitted in the CMS report that she did not look at the order. So yes, she took a verbal. This becomes obvious as the order stated to give 1mg, monitor effect and repeat with an additional 1mg if needed but RV couldn’t remember how much she gave and the syringes weren’t marked.
What page of the CMS report are you referring to? Even if that were the case, I'm not sure how you feel that would have changed the course of events.
I'll give you the statute again. Can you cite where intent to kill is required? She choose to type in two letters and push the first thing that popped up. That was a choice. She didn't mistake a med with a similar name, she choose to over-ride and push the first medicine that opened. That was reckless disregard for norms.
You should play a game the next time you are at work. Go to the Pyxs, over-ride it and type in various first two letters--- see if it will kill a person. Maybe start with "Ca." Who knows?!
Here is the statute, show me where intent to kill is in the statute
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.
To clarify, are you under the impression that she recognized the first medication that came up in the search results was not the drug she was looking for, but removed it anyway; ie that she knew all along she didn't have the correct drug?
Again, to meet the definition of the statute the person has to consciously disregard a substantial and unjustifiable risk. If, due to error or other failures, you are not aware of the substantial and unjustifiable risk then that is not conscious disregard.
To clarify, are you under the impression that she recognized the first medication that came up in the search results was not the drug she was looking for, but removed it anyway; ie that she knew all along she didn't have the correct drug?
I suggest you read the report. She stated she never even looked at the name of the med she pushed IV (PARALYTIC PARALYTIC) , so no, she didn't recognize it as the wrong med.
Again, to meet the definition of the statute the person has to consciously disregard a substantial and unjustifiable risk.
She typed in two letters and pushed the first med IV that happened to open. She made a choice to do that. She didn't mistake one med for another or anything like that. She consciously choose to type in two letters and push the first thing that popped up.
She fits the statute in a textbook fashion when she made a choice to ignore all safety norms.
I'm not sure why you don't understand that she made a choice to just type in two letters and push the first thing that popped open. She stated as much in the report. It was a choice.
p.s
I know we have all kinds of RNs here and I'm just a student, but have you ever used a Pyxs? You can over-ride it and get it to do whatever you want. Hell, you could make it cough up and Pepto and push that IV if you wanted to.
She fits the statute in a textbook fashion when she made a choice to ignore all safety norms.
I'm not sure why you don't understand that she made a choice to just type in two letters and push the first thing that popped open. She stated as much in the report. It was a choice.
p.s
I know we have all kinds of RNs here and I'm just a student, but have you ever used a Pyxs? You can over-ride it and get it to do whatever you want. Hell, you could make it cough up and Pepto and push that IV if you wanted to.
Hitting the first thing on the list after typing a couple letter is well recognized habit that occurs with the use of ADCs, which isn't a conscious choice, that's what a habit is. Your brain gets repetitive feedback that most often after typing a couple of letters the intended drug is at the top of list. It's a common enough issue that at a couple of places I've worked they've blocked the predictive text until at least 4 characters have been typed in. At one we even added 'dummie' results that would show up a the top of the list that would then remind the nurse to carefully read the results before picking one.
MunoRN, RN
8,058 Posts
It would appear unlikely that she utilized the override function while thinking "this will likely kill someone, but I'm going to do it anyway" which is what the statute requires, it's more likely that she wasn't aware of the harm that was likely to result.
From ISMP's statement: