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Another Tragedy at Vanderbilt

Nurses   (8,319 Views 161 Comments)
by Nurse Beth Nurse Beth, MSN (Advice Column) Writer Innovator Expert

Nurse Beth has 30 years experience as a MSN and specializes in Med Surg, Tele, ICU, Ortho.

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The nurses are the easiest to throw under the bus. Do you think they want to get rid of their surgeon and start with someone else?

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4 hours 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"? 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?" 

 

I'm going to play devil's advocate and say yes. Time outs in surgeries/procedures are just as important as the 5 rights. That everyone in the team plum forgot is a bit of a stretch, particularly when it needs to be documented. I don't agree with the argument that this form of negligence is less purposeful than the other.

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6 minutes ago, cleback said:

That everyone in the team plum forgot is a bit of a stretch, particularly when it needs to be documented.

I would really like to know when this occurred in relation to new EMR implementation, which I believe was the same month.

Although there's no excuse.

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HomeBound has 20 years experience and specializes in ED, ICU, Prehospital.

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From The Tennessean: 

"Both of those errors were deadly (*referencing the vecuronium incident vs. the kidney stent incident), but they still don't carry the notorious reputation of a "wrong-site surgery," which are among the rarest mistakes in modern medicine. The U.S. Department of Health and Human Services says these "vivid and terrifying errors" occur once in every 112,000 surgeries and at individual hospitals maybe once in every five or 10 years. Federal officials classify wrong-site surgeries as "never events" and say these errors are often signs of "serious underlying safety problems” at hospitals, according to a safety primer published by the federal agency earlier this year." (emphasis mine)

This is apples and oranges in some ways, but it still comes down to Vanderbilt's (and most other enormous "teaching" hospitals) culture of laissez faire when it comes to basic safety.

I just spoke to a former RN from Vandy, who actually gave money to RV's "pay my legal bills for me" fund.

He doesn't believe in her. Not at all. He thinks she should lose her license and then be sued into next Tuesday civilly by the family.

No, he gave because he doesn't want the supposed "backlash" of the outcome negatively effecting-----him and his practice.

I am about done with everyone who is defending these mistakes---like ZDogg did--not because it's wrong, or patients won't benefit---but because it might effect the profession--meaning, people are going to have their feet held to the fire on their performance. Can't have that.

This physician will have his feet held to the fire. Just as any other physician that has had this "never event" happen to them. What you don't understand is that physicians can't get malpractice insurance after an even like this--and that is actually worse than having their medical license revoked. They literally have the capacity to work, but cannot---because no one will hire them, and no one will insure them even if they get hired somewhere. Hospital risk management steps in on these cases. Then the families can go after the MD in civil court and ruin them financially.

Yeah, crappy doctors work. The old joke goes again---what do you call the person who graduates last in their medical school class?  Doctor.

What do you call a nurse who graduates last in their nursing class? Nurse.

Which is why I don't comprehend this overarching support, without any logic, is being thrown behind RV---there are bad nurses and bad doctors and bad policemen and bad priests and bad school teachers and bad horse jockeys. 

There is a percentage of the population that are sociopaths, psychopaths, borderline, functional alcoholics, functional drug addicts---and do they all live homeless under a bridge so we can all identify them?  No. They don't. They go to and graduate from prestigious schools and move forward to prestigious places.

Vanderbilt has a serious problem with their culture. I was told point blank---the crew is green, because Vandy wants to pay the least for the most. You want our name? You do what we tell you to do. My friend told me that he was CHARGE NURSE on a step down unit within 6 months of graduating, while working at Vandy.

Here's another point.

I've worked for big, hulking "teaching" "magnet" "level 1" hospitals.

I would not go to even one of them to have a surgical procedure. Not one. Because of this crap TEACHING thing. The hospitals allow attendings to prance in at the last moment, while everyone genuflects---to do 3 minutes' worth of whatever it is---then prance out---

forcing the residents, fellows and other "still in school" (technically) to do the hard work. You know.....the time-outs and the site marking.

Anesthesiologists send their residents to do consenting. Surgeons send their PAs or NPs to do the legwork. In surgery, I've seen 5th year residents doing practically the entire procedure---

where is the attending??

It's the culture of these big, ridiculous "magnet" "teaching" hospitals that provides the rich breeding ground for "doing whatever" because there is no oversight.

But hey. They've got great sports teams! What a great name to have on your resume!

I was told by another large southern system---you want our name on your resume? You will take what we give you. You say one negative thing? We will make sure you won't work in this state again.

/rant over

The question you posed, Beth, is insulting. I thought that the first time you posted the vec vs. versed thing was really to inform. Then it kept coming---trying to stir up sympathy for this nurse not because of the facts of her negligence, but to instill fear into nurses that "this might happen to you if you let this happen to her".

Now this "us vs. them" thing. The physicians are held responsible. Did this doctor come in and literally say..."HEY! I have an idea! Let's forego the time out!!" (overriding the pyxis)  and then  "HEY! Even though that rad tech took the xray and it says LEFT and not RIGHT, let's just dig into the right kidney anyway!" (overriding the warning about paralytics, reading the label and ignoring it, reconstituting-showing inexperience/ignorance of her own job)

There is a huggggggggggggggggggggggge difference between what RV did and what this MD did. 

Where was the circulating nurse? Where was the resident? Where was the anesthesiologist? Where was the surgical technologist? Where was the surgical nurse?

If the MD is held responsible, so should everyone else in that room. Including the nurses.

Again.....there are bad nurses and bad doctors. Vandy's culture is such that they will hire anyone that is willing to do exactly what these other enormous teaching hospitals demand of their hires----you work cheap and you shut your mouth or else. It's our way or the highway with a big black mark on you for daring to criticize.

 

 

 

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I don't have any IR experience, but I have been in the OR and I can't see how a surgeon would have been able to execute a wrong-site kidney stenting without a whole roomful of negligent people standing by. 

Besides, what a waste of public funds to pursue these individuals as criminals and pay for their upkeep as inmates. Good grief! Suspend their licenses. Require them to be part of the root analysis. Refer them to remedial training. Make their ongoing employment in the facility contingent on involvement in process-improvement. Get them away from the bedside... the options are vast.

Sentinel events occur when system failure culminates in one person making that final deadly/destructive mistake. These individuals passed their academic/licensing requirements, and I assume the must know the right thing to do in theory. So why didn't they do it? Persecuting one or two people isn't going to facilitate change in the culture -- it's going to promote the practice of blaming 100% of the problem on the guiltiest individual, even if they only account for a fraction of the failure. It doesn't make sense to look at what they did without looking at the pressures and culture that contributed. Unfortunately, that's not really how our legal system functions now, is it?

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DextersDisciple has 5 years experience as a BSN, RN.

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@HomeBoundforcing the residents, fellows and other "still in school" (technically) to do the hard work. You know.....the time-outs and the site marking.

IR nurse here- just wanted to point out that we cannot perform time out until the attending is present. However some pop in just for time out 🤷🏼‍♀️

Edited by DextersDisciple

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Ruby Vee has 40 years experience as a BSN and specializes in CCU, SICU, CVSICU, Precepting & Teaching.

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On 3/21/2019 at 8:39 AM, cleback said:

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

I agree.  I think it's a start down a slippery slope.

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Asystole RN is a BSN, RN and specializes in Vascular Access, Infusion Therapy.

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13 minutes ago, Ruby Vee said:

I agree.  I think it's a start down a slippery slope.

This slope has been sloping for many, many decades. The only difference was a fateful slow news cycle where one nurse was highlighted in the news. 

My mother was on a board of nursing for a large state many decades ago and was aware and involved in several cases where nurses were criminally charged for one mistake or another. 

Edited by Asystole RN

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43 minutes ago, Ruby Vee said:

I agree.  I think it's a start down a slippery slope.

That argument hasn’t really been proven true. Another poster did a search and found only 3 cases, including RV, since the late 90’s. None have resulted in jail time. 

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Well again,...I've investigated situations at Vanderbilt many times....giving the wrong blood type to an OR patient...not having the open heart bypass equipment clean...transplanting the wrong blood type liver into a patient...and several more.  This is all public record with the 2567 and the plan of correction which must be available to public.  In my opinion, Vanderbilt gives excellent care to the vast majority of it's patients.  Do they make terrible mistakes? Yes, it is a teaching hospital with many levels of students, interns, residents. 

 Flame away, those who are not in the know.

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

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9 minutes ago, twinsmom788 said:

Well again,...I've investigated situations at Vanderbilt many times...

Vanderbilt gives excellent care to the vast majority of it's patients. 

 

 

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