Another Tragedy at Vanderbilt

[Nurse Beth]

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?

[cleback]

8 hours ago, Asystole RN said:

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.

Interesting. Thank you for the info.

[Jory, MSN, APRN, CNM]

On 3/24/2019 at 6:54 PM, MunoRN said:

RV failed to check the medication against the order when pulling the med, the physician in this incident failed to check that their signature/initials over the actual site against the imaging/dx that defined the target kidney (or failed to sign the site at all). RV then again failed to check the label just prior to administering just as the physician in this incident failed to confirm the site just prior to the procedure.

The details are of the two safety mechanism failures differ, but I don't see how they are two completely different levels of failure.

We haven't seen an official report...my guess is that the time out occurred, but the wrong site was documented at some point along the way. Therefore, when the procedure started, the surgeon thought they were working on the correct site because they rely on the whoever is calling out the procedure to be correct.

This is why we do a root cause analysis. All we know is the wrong site was operated on...we don't know WHY that happened.

[Jory, MSN, APRN, CNM]

On 3/24/2019 at 7:56 PM, MunoRN said:

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.

Whoever asked that question was an idiot, because if you pull up the definition in the state statute, it meets ALL of the criteria. It also matches it per definition in the Black's Law Dictionary.

[Jory, MSN, APRN, CNM]

On 3/24/2019 at 8:01 PM, MunoRN said:

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.

Have you ever pulled a med from the Pyxis? Because that isn't how they work. You think at the first drug you pull up after only a couple of letters is even 99% of the time the right one?

Well, it's not.

[Wuzzie]

5 hours ago, MunoRN said:

It's not actually the Standard of Practice to provide 1:1 monitoring after every IV push medication,

It’s not 1:1 monitoring. It’s waiting a minute or two and watching for an adverse reaction and it is standard of practice. It has never been acceptable practice to give an IV push med and just walk away, certainly not slam it in and walk away.

[Wuzzie]

6 hours ago, MunoRN said:

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:

I directly quoted Clebak’s question in my response so I’m not sure what you’re getting at.

Oh and your snark did not go unnoticed, I’m currently searching for some aloe. Might need to run to the store. ?

[cleback]

10 hours ago, Wuzzie said:

I directly quoted Clebak’s question in my response so I’m not sure what you’re getting at.

Oh and your snark did not go unnoticed, I’m currently searching for some aloe. Might need to run to the store. ?

Muno was correct. I didn't pick up any snark... but I don't agree with your argument for the same reasons Muno pointed out. I've certainly given iv methylpred and moved onto the next task. Monitoring depends on the drug, purpose, and facility policy.

[Asystole RN]

16 hours ago, MunoRN said:

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.

It can be said that it is a standard of practice to monitor and assess the patient for adverse reactions regardless of the medication. Considering the the method of delivery and the type of medication, IVP meds may necessitate a greater level of assessment.

The need for assessment is a prime reason why lower levels of licensure (LPNs, CNA, etc) are prohibited from giving IVP medication.

Now you can argue maybe it does not require assessment but ask yourself, are you confident a jury of laypersons would not see a very brief assessment after rapidly giving IVP medications which is generally restricted to more advanced clinicians such as registered nurses as unreasonable?

My guess most people would vote it was reasonable to check in on a patient after giving IVP medications.

[Asystole RN]

13 minutes ago, cleback said:

Muno was correct. I didn't pick up any snark... but I don't agree with your argument for the same reasons Muno pointed out. I've certainly given iv methylpred and moved onto the next task. Monitoring depends on the drug, purpose, and facility policy.

Have you ever asked yourself why LPN/LVNs, CNAs, or phlebotomist do not give IVP medications? Lets be honest, as a task it is not complicated and any lay person can physically give IVP medications. Why would the practice be so restricted to registered nurses?

Is a brief peak on your patient after you give "dangerous" medications unreasonable?

[Wuzzie]

16 minutes ago, cleback said:

I didn't pick up any snark.

It wasn't related to your question.

[Wuzzie]

18 minutes ago, cleback said:

Muno was correct.

I thought I was answering the question I quoted. Sorry if I was mistaken.

[missmollie, ADN, BSN, RN]

Does it matter if it was an RN or a Doctor who made a life changing error? Sure, yes, it does.

An Rn is responsible for administering medications, and should ensure it is the right does, right patient, etc.

A doctor is taking out a kidney. He should know which one. He gets paid at least 5-10x our salary to ensure the right organ is coming out. It is literally one doctor (or more) to one patient. They do not have to chart during this time. They do not have a 1:2, a 1:3, a 1:5, or 6, or 7 load to handle. They have one job during surgery. Why would any of you turn this into a nurse drew Vecuronium to a doctor taking out a kidney. Both were mistakes by humans. Both were in the same system. How dare you. Shame.

Perhaps the blame does belong to the system and not so much on the individual employees. Don't you dare draw a comparison, since so many were so eager to hang this nurse out to dry. Do the same for the doctor, or at least acknowledge there is a fault in the system.