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?
Talk about breakdown in communication ,look at this site how many here have misread and reacted incorrectly to the article where two different cases are discussed.That is right two cases.
I posted about this in the nursing news section the other day. 3 major incidents within a year of one another. What's going on at Vanderbilt? I was looking into their NP programs but nope! They're losing their elite status because there's too much going on. It's no longer worth the amount of money for the reputation they now have with all these incidents.
Please. Physicians do stuff like this and regularly are not held to the same standards as a nurse would be. I know of a few specific incidents where physicians have removed the wrong kidney and have event amputated the wrong limb and continue to practice. If RV is being criminally charged, so should the physician. It is unreal that this could happen especially at a place like Vandy.
If RV is being criminally charged, so should the physician.
This is very different than what happened in the RV case and I believe there is more to this story as some of the details don’t add up. A simple stent placement in a normal kidney even if it’s the wrong kidney should not result in a patient needing dialysis for “life”. Regardless, the physician was not the only person tasked with assuring that the correct surgical site was chosen. The “time out” procedure involves the majority of the OR team. There is a system component to this as well as individual. Hopefully the licenses of all involved have been impacted and the surgeon, as the team leader, should have his pulled. The rest seems more suited for a civil action. Now, if the surgeon refused to scrub, didn’t wear a mask or sterile gloves, wiped the instruments on his jeans before using them, sneezed into the incision, got the mesh tubing from Quality Farm and Fleet and closed the patient with stuff from his mom’s sewing kit then perhaps criminal charges would be appropriate.
This is very different than what happened in the RV case and I believe there is more to this story as some of the details don’t add up. A simple stent placement in a normal kidney even if it’s the wrong kidney should not result in a patient needing dialysis for “life”.
This is very different than what happened in the RV case and I believe there is more to this story as some of the details don’t add up. A simple stent placement in a normal kidney even if it’s the wrong kidney should not result in a patient needing dialysis for “life”. Regardless, the physician was not the only person tasked with assuring that the correct surgical site was chosen. The “time out” procedure involves the majority of the OR team. There is a system component to this as well as individual. Hopefully the licenses of all involved have been impacted and the surgeon, as the team leader, should have his pulled. The rest seems more suited for a civil action. Now, if the surgeon refused to scrub, didn’t wear a mask or sterile gloves, wiped the instruments on his jeans before using them, sneezed into the incision, got the mesh tubing from Quality Farm and Fleet and closed the patient with stuff from his mom’s sewing kit then perhaps criminal charges would be appropriate.
I think this case and the RV case have more in common than you're acknowledging.
Like RV, this incident could have been avoided had the individual followed some basic safety rules, in this case confirming the site by checking the pre-op imaging at the beginning of the case, essentially the same as checking the medication label just prior to administering.
Like the RV case, there were systemic failures that also contributed. I'm not sure then why the Crux of the failure in the RV case was the individual failure yet in this case it was the systemic failure more than the individual.
Like RV, this incident could have been avoided had the individual followed some basic safety rules, in this case confirming the site by checking the pre-op imaging at the beginning of the case, essentially the same as checking the medication label just prior to administering.
Like the RV case, there were systemic failures that also contributed. I'm not sure then why the Crux of the failure in the RV case was the individual failure yet in this case it was the systemic failure more than the individual.
Because if RV had followed even ONE of the standards of medication administration after not looking at the vial the patient likely would have not died. That is what makes it different which I thought was pretty clear when I listed several other things the surgeon could have done that would have made me think it was criminal. As far as I’m concerned there were no systemic errors that caused RV to act as she did. That was entirely on her and nobody else. She alone is responsible for her practice.
Also, the facts aren’t lining up for what happened to this patient so I’m reserving judgment until I have more details.
Wow that's crazy, such an unnecessary thing to have happened. I wonder how Vanderbilt will survive with these lawsuits over a million dollars and their reputation is taking a big hit i'm sure. I know they have insurance but its still a lot of money.
Wow that's crazy, such an unnecessary thing to have happened. I wonder how Vanderbilt will survive with these lawsuits over a million dollars and their reputation is taking a big hit i'm sure. I know they have insurance but its still a lot of money.
Vanderbilt has a very large donor population. It will survive all this and more. If you have ever been to a homecoming game and listened to the announcements of gifts, your head would spin. And that's just the tip of the iceberg.
Specializes in ER - trauma/cardiac/burns. IV start spec.
On 3/21/2019 at 12:23 PM, Daisy4RN said:
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.
The first thought that popped into my head was the Willie King mess from 1995 or 1996. The surgeon amputated the wrong foot. Shortly after that happened patients began to write things like "not this leg/foot/arm" and also "this leg/foot/arm" on themselves before surgery in marker. I even put a star on the side with the kidney that needed a stent before going in.
And Yes Residents do need more supervision, I had one accept a patient from a small rural hospital that was a snake bite victim. The Resident did not ask or receive any information as to treatment there, condition of patient, just that he was bitten by a rattler. He did not even contact his Attending or the House Supervisor. It was a mess and on top of that the two Residents were arguing over who would intubate while I was calling sats out like a countdown, 90, 88, 86, 84, 82, 80, 78, at which point our ER physician took over. The Resident argued with all of us in the ER that night. I do not know what would have happened had the patient suffered permanent injuries or death, glad it came out well as my name was the one on the line for all the antivenin we had to call in. Sometimes staff is doing everything they can and are not responsible for the ultimate foul up.
Oh yes the Resident was let go from the program very shortly thereafter.
Specializes in RN critical care,traveler,critical care float,CNA5.
I seriously cannot believe that people want that nurse to go to prison for manslaughter. What she did was negligent, definitely not manslaughter. And if she is convicted of manslaughter it's going set a dangerous precedent for nurses as far as case law goes. Regarding the Verconium incident she was honest from the beginning, Vanderbilt hid the truth from the family for months. Despite that fact some how that nurse is going to be a scapegoat for manslaughter instead of negligence. There's alot wrong with this situation.
Leader25, ASN, BSN, RN
1,348 Posts
Talk about breakdown in communication ,look at this site how many here have misread and reacted incorrectly to the article where two different cases are discussed.That is right two cases.