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?
There was also a new lawsuit a few weeks ago against Vanderbilt for wrongful death due to a stroke resulting from placing a central line in the carotid artery instead of the jugular, this was an unsupervised resident physician placing the line.
Like the Vecuronium incident, this wasn't helped by excessive diagnostics/treatment, the central line was placed because Vasopressin was ordered, even though the patient's BP when the Vaso was ordered was 131/77 and the patient had never been hypotensive.
To clarify the charges against RV, she isn't actually being charged for making a med error, she's being charged for using the override function of the pyxis, which at least at place I've worked is far from qualifying as negligence, it's often an expected part of nursing practice in many situations.
Not exactly, RV is being charged, per reports from the DA office, for overriding MULTIPLE checkpoints...not just one. I personally counted 7 in total.
She was negligent, in order for reckless homicide to be what occurred she had to intentionally or knowingly give the wrong medicine. She did neither of those things. She did negligently override the necessary safe guard. And yes due to her negligent behavior a patient died. She was trying to pull Versed and put the name brand name instead of the generic, it was unintentionally done and fits more into negligence.
Actually...no. In Tennessee INTENT is not part of the charge nor in most states.
If she intentionally meant to kill the patient, they would charge her with murder.
Homicide is not the same as murder.
It's also very clear you didn't read the CMS report. She did, INTENTIONALLY put in the brand name instead of the generic. If you don't find the drug you are looking for, you don't pull it. Period.
I mean, how stupid does a nurse have to be when they don't even find a drug close to what they are looking for and then just say, meh..close enough. That is exactly...what RV did.
Not exactly, RV is being charged, per reports from the DA office, for overriding MULTIPLE checkpoints...not just one. I personally counted 7 in total.
The initial statement from the DA's office was that she was being charged due to a number of errors, when it was pointed out that it doesn't appear any of this errors meet the legal definition of negligence, a spokesperson for the DA office clarified the legally defined negligence occurred when RV used the override function.
Actually...no. In Tennessee INTENT is not part of the charge nor in most states.
If she intentionally meant to kill the patient, they would charge her with murder.
Homicide is not the same as murder.
It's also very clear you didn't read the CMS report. She did, INTENTIONALLY put in the brand name instead of the generic. If you don't find the drug you are looking for, you don't pull it. Period.
I mean, how stupid does a nurse have to be when they don't even find a drug close to what they are looking for and then just say, meh..close enough. That is exactly...what RV did.
I'm not sure where you're getting that she knowingly removed the wrong.
The default setting for Pyxis machines is to use predictive text based on the first two letters entered. This produces the bad habit of entering two letters then hitting the first drug listed, since most of the time that's the one you're looking for.
Specializes in Psych, Corrections, Med-Surg, Ambulatory.
10 hours ago, fibroblast said:
Sorry if I've repeated anyones post, but from what I understand this resident is still employed at the hospital. The nurse was terminated. Wow.
I don't believe the nurse should be among criminal status such as murderers and thieves. Everyone to some extent has cut corners, maybe not safety violations but when they are short staffed or an emergency, someone has to have over road some policy.
If you read the CMS report and the Tennessee statutes, you will see that the charges are appropriate. Cutting corners during medication administration is a very bad idea. This nurse did way more than cut corners. She did not practice at the level required of a registered nurse. Her actions were nothing short of reckless.
As to this current situation of the wrong kidney being operated on, so far I just haven't seen enough information to form an opinion as to who is liable and if anyone's actions fit any description in the criminal code.
I've been checking back on this thread... and so far no one has attempted to argue why not checking a procedural site (time out, sit marking, etc) is any less negligent than not checking a medication (5 rights). I think that is a big problem.
I have to wonder if the real reason these cases tend to go to civil instead of criminal court isn't because actions don't fit a definition but rather for financial reasons. One doesn't get a monetary settlement in criminal court. And obviously, if the patient was severely injured, they're probably going to need the money.
I've been checking back on this thread... and so far no one has attempted to argue why not checking a procedural site (time out, sit marking, etc) is any less negligent than not checking a medication (5 rights). I think that is a big problem.
I have to wonder if the real reason these cases tend to go to civil instead of criminal court isn't because actions don't fit a definition but rather for financial reasons. One doesn't get a monetary settlement in criminal court. And obviously, if the patient was severely injured, they're probably going to need the money.
If someone wanted to win a large civil case it is in their best interest to encourage an initial criminal case in which sometimes monetary compensation is rewarded as well. Generally, criminal cases do not impinge upon your right to file a civil case after the criminal case. See California v. OJ Simpson as a prime example.
There are many factors that impact whether a case will go to court or not. Things like does it meet a definition? What is the strength or likelihood of success? Will the case provide justice or protect the community? Or sometimes it is as simple as if the prosecutor has time for such a trial.
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.
12 minutes ago, cleback said:
I've been checking back on this thread... and so far no one has attempted to argue why not checking a procedural site (time out, sit marking, etc) is any less negligent than not checking a medication (5 rights). I think that is a big problem.
I actually have answered. The difference so far is firstly I have yet to see an official report of the events that occurred regarding the renal surgery and am waiting for a more reliable source than the media. Secondly, RV did not just make one mistake. She made an astoundingly huge number of egregiously poor decisions and demonstrated a level of nursing care so far below even the basic standards that it truly blows my mind that anyone would be supportive of her hence my description of what would lead me to believe that criminal charges should be brought against the surgeon.
Let me reiterate what I have stated before. What pushed me into the realm of believing the charges against RV are just is not the override or even pulling the wrong med (although come on). It is the fact that she gave an IV push medication and then peaced-out without even monitoring the patient which we, every. single. one. of. us, are taught in NURSING SCHOOL is a big no-no. That was the nail in the coffin for me. That was the negligence.
Let me reiterate what I have stated before. What pushed me into the realm of believing the charges against RV are just is not the override or even pulling the wrong med (although come on). It is the fact that she gave an IV push medication and then peaced-out without even monitoring the patient which we, every. single. one. of. us, are taught in NURSING SCHOOL is a big no-no. That was the nail in the coffin for me. That was the negligence.
Agree with this.
I've been able to separate things out in my mind finally after all the discussion here.
My problem is that I feel that despite all the lofty nursing talk and the nursing practice councils and ideas of nurse-generated EBP and all the focus on nurse education and leadership blah, blah, blah, hospitals have somehow lost all focus with regard to actual nursing - - AEB the current thread about people running around reassessing things that don't need to be assessed and checking a bunch of boxes so they don't get written up, etc.
The lack of a prudent nursing-specific "focus" in RVs actions (like the idea of giving a med and moving on to the next thing) just does not shock me. I see it (in less tragic ways) all the living day long. Everybody is more concerned about what a policy says or what they might get written up for or doing their tiny piece of some kind of "teamwork" that amounts to not requiring any one person to have any big picture about any one patient. You can hear it in the kind of nursing reports people give (a run down of tasks done and not done), you see it in their thought processes and subsequent actions, that what is really going on here is 'doing a bunch of currently-approved tasks,' rather than assessing a patient and intervening according to that patient's needs. If the next day some PTB declares that we don't need to do X thing any more, then just like that we don't need to do it any more. How are we doing things today (what is being audited right now)?
In my mind still, I look at that RV/CM case and I see this ^ all through it. NO ONE planned anything for this lady's care overall. It was a series of tasks involving a series of individuals (not the errors themselves but the lack of an individualized plan). CM would be alive if RV had read a label or monitored a patient. CM would also be alive if the expectation was that her nurse had an individualized POC that was actually thought-out and followed. That person would understand a patient's status was upgraded, she was off monitors, she has a PET scan coming up later. Will she need an anxiolytic to tolerate that? Yes? Get an order for something PO, administer an hour or so ahead of the procedure, talk with rad staff to coordinate care. Fully assess the situation to know whether/how the patient will (or won't) be monitored by rad staff while waiting and during the procedure.
Patient stays alive.
This "right care at the right time" BS amounts to every single act of care being a fake hair-on-fire situation, with no one having to concern themselves with anything except doing "this thing," and doing it "right now."
I find it all (the whole larger hospital situation) so disappointingly unacceptable that I still can't think about that case without wanting someone to answer for "this". All of it everywhere. I think institutions need to answer for their part - which IMO is encouraging this unthinking assembly line mentality. RV can answer for her actions, too.
I actually have answered. The difference so far is firstly I have yet to see an official report of the events that occurred regarding the renal surgery and am waiting for a more reliable source than the media. Secondly, RV did not just make one mistake. She made an astoundingly huge number of egregiously poor decisions and demonstrated a level of nursing care so far below even the basic standards that it truly blows my mind that anyone would be supportive of her hence my description of what would lead me to believe that criminal charges should be brought against the surgeon.
Let me reiterate what I have stated before. What pushed me into the realm of believing the charges against RV are just is not the override or even pulling the wrong med (although come on). It is the fact that she gave an IV push medication and then peaced-out without even monitoring the patient which we, every. single. one. of. us, are taught in NURSING SCHOOL is a big no-no. That was the nail in the coffin for me. That was the negligence.
I think cleback might have been referring to this, which posted a few pages ago but I think you missed it during the Thumps up/Thumps down debate:
Quote
It's a fairly standard safety rule that the practitioner who is performing a procedure check the pre-op imaging/diagnostics to confirm the correct site, I wouldn't say it's any less of a rule than checking the medication label prior to giving a med. Just as with RV, had he done that, the incident likely would have been avoided, so why is RV alone responsible for her practice while the physician in this incident isn't?
To clarify the charges against RV, she isn't actually being charged for making a med error, she's being charged for using the override function of the pyxis, which at least at place I've worked is far from qualifying as negligence, it's often an expected part of nursing practice in many situations.
I actually have answered. The difference so far is firstly I have yet to see an official report of the events that occurred regarding the renal surgery and am waiting for a more reliable source than the media. Secondly, RV did not just make one mistake. She made an astoundingly huge number of egregiously poor decisions and demonstrated a level of nursing care so far below even the basic standards that it truly blows my mind that anyone would be supportive of her hence my description of what would lead me to believe that criminal charges should be brought against the surgeon.
Let me reiterate what I have stated before. What pushed me into the realm of believing the charges against RV are just is not the override or even pulling the wrong med (although come on). It is the fact that she gave an IV push medication and then peaced-out without even monitoring the patient which we, every. single. one. of. us, are taught in NURSING SCHOOL is a big no-no. That was the nail in the coffin for me. That was the negligence.
It's not actually the Standard of Practice to provide 1:1 monitoring after every IV push medication, that's what differentiates moderate sedation from other medication administrations. I don't recall that being taught in nursing school, although what defines negligence is something that is so egregious it's extremely rare and every instance where it occurs is worthy of loss of license and potentially criminal charges, it's not defined by what is ideal practice. Giving an IV medication and then moving on to your next task is far, far too common of a practice to qualify as negligence.
Jory, MSN, APRN, CNM
1,486 Posts
Classic example of "resident needed their numbers".