Latest on RaDonda Vaught case

Published

RaDonda Vaught made at least 10 mistakes in fatal Vanderbilt medication error, prosecutors say

This article outlines details of the prosecution's case. I am curious as to how the defense plans to pin this on the hospital?

I still can't fathom why the Tennessee BON didn't see fit to require at least some reeducation of Ms Vaught!

Specializes in NICU/Neonatal transport.
49 minutes ago, Jory said:

No...bypassing MULTIPLE systems of safety has nothing to do with "just culture". It has to do with incompetent nursing and this is what the BON is designed do....discipline these nurses to protect the public.

If we do not have a line in nursing where this eventually becomes criminal...then we have lost who we are as a profession. A group of college graduates with a professional license should not have to be baby-sat.

It would if you feel she made an "error". RV didn't make an error. She was a sloppy nurse that has probably done similar things on the regular (I haven't bypassed that many systems of safety in my entire career) and it just flat out--caught up with her.

I completely agree with you, I was just echoing what I've heard a lot of nurses who have defended her actions say. blah blah blah, aren't we supposed to have just culture and not be blamed for our mistakes and it was a systems problem not my problem? I disagree vehemently.

I also agree she was a sloppy nurse - you do not go from being safe and conscientious to this level of negligence (with an orientee watching even!) unless you are impaired by drugs/alcohol. This is someone who didn't have the habit of good practices that she was just continuing.

3
Up Vote Up Vote ×
5 hours ago, LilPeanut said:

I can address this a little, knowing EPIC well. When you override a medication on the pyxis under a patient name, it automatically goes to the MAR so it can be signed off. When you scan the med, it will say "link to override pull of x med?" It's in a different color box (pink maybe?). Now, it doesn't record it as given, it just puts it in the MAR in preparation for being signed off. Epic was relatively recently new to the hospital, and my guess is the NM did not understand the difference between those two things. She knew that if you overrode something, it would automatically go to the MAR, but not that it wouldn't document as given (and I think the override pull eventually will drop off if you don't sign it). Everyone should have known that she should have signed off the med she gave, but the likelihood that it was in any way intentional is low, IMO

I'll go into conspiracy more later.

I would never suggest that the NM thought fast enough to advise her not to document it for the purpose of a cover-up. My comment was to address the half-assed knowledge that is rife everywhere and the preoccupation with big technologies such that no one making decisions about patient care but not taking care of patients even cares how they really work or how they fit into individual patient care scenarios.

I am aware of how the procedure works with Pyxis, although it has now been noted that Omnicell was the ADC in use so the procedure may not be exactly the same anyway.

My contention is exactly as yours - unfamiliarity. That doesn't invoke my sympathies since I have no idea what kind of excuse it is to say that we are unfamiliar with our technology.

And yes it is a very big deal whether - - - intentional - - - or not, since not having that medication documented is the very fine thread of an excuse that officially allowed the error to be called hearsay. Think about that.

2
Up Vote Up Vote ×
Specializes in NICU/Neonatal transport.
42 minutes ago, JKL33 said:

I would never suggest that the NM thought fast enough to advise her not to document it for the purpose of a cover-up. My comment was to address the half-assed knowledge that is rife everywhere and the preoccupation with big technologies such that no one making decisions about patient care but not taking care of patients even cares how they really work or how they fit into individual patient care scenarios.

I am aware of how the procedure works with Pyxis, although it has now been noted that Omnicell was the ADC in use so the procedure may not be exactly the same anyway.

My contention is exactly as yours - unfamiliarity. That doesn't invoke my sympathies since I have no idea what kind of excuse it is to say that we are unfamiliar with our technology.

And yes it is a very big deal whether - - - intentional - - - or not, since not having that medication documented is the very fine thread of an excuse that officially allowed the error to be called hearsay. Think about that.

Right, but the unfamiliarity led to the lack of documentation, which led to the hesitation of the doctor to be the "first one" to say to an official that it was from an error. The doc was absolutely wrong, but I have no suspicion that it was to implement a "cover up". It was a nervous physician who wasn't sure what s/he was supposed to say.

1
Up Vote Up Vote ×
6 hours ago, LilPeanut said:

Maybe this is just the bitter nerd in me, but I find popular girls can get away with anything and still sail through. I bet no one noticed because she's "so sweet".

Being 'young' and 'pretty' also seems to help in the court of public opinion. God help us old, tired, jaded and homely souls!

2
Up Vote Up Vote ×
6 hours ago, LilPeanut said:

So the nurse manager is dealing with it initially, is not great with Epic yet and mistakenly tells RV that she doesn't need to document the med given, because she thinks the fact it knows the med was pulled from the pyxis/accudose is enough. Mistake, not conspiracy 

Okay but you're the manager. You have someone sitting in your office under these terrible pretenses.

So you tell them they don't need to document that it was given because "Epic." ?

Do you think you might ask and make sure that other nursing documentation bases are covered? You know, such as what happened?

No? Well that is unacceptable nursing ignorance + a particular culture obsessed with everything except the patient.

The freaking EMR is still a record about the patient. I get that there is no specific Epic narrator for such a situation and no check box either, but it still has to be documented.

6 hours ago, LilPeanut said:

Then you have a resident (most likely) who was the one who called the ME, and then was hedging on what happened. S/he knew that everyone had been talking about it, but didn't know how far outside of the unit it was supposed to go, the whole thin white line. So he says "“maybe there was a medication error but that was just hearsay, and nothing has been documented in the medical record. There was no named drug in the notes.”" Now, at this point the ME should have asked more questions, or automatically sent the patient for autopsy. That was their failures, but not a conspiracy.

No. You're saying that information that was good enough to make a prognosis that supported the withdrawal of life support was then the same information that no one was sure enough about to report to the ME.

Nope.

Quote

S/he knew that everyone had been talking about it, but didn't know how far outside of the unit it was supposed to go, the whole thin white line. So he says "“maybe there was a medication error but that was just hearsay, and nothing has been documented in the medical record. There was no named drug in the notes.”

First of all, that is not even true according to the CMS report. A nurse practitioner did note something to the effect, "current meds - vecuronium" [paraphrase].

Secondly, not knowing how far out of the unit something is "supposed to go" is a concept that may apply to generally conversational discussion of the case - - but does not apply to withholding information that you are legally and ethically obligated to report.

I really don't care about thin white lines as you are using them in context. That is BS. It is an absolute lie, no matter why it was done - - exactly the same way that RVs actions can be considered reckless whether she meant to hurt anyone or not.

And I still don't think that people cared for this patient, consulted with each other about this patient, dealt with all the particular practicalities of a huge error, came to a prognosis, and decided with the family to withdraw care, without thinking or talking one bit about it being an ME case. Nope. If so, then those residents don't have enough direction and supervision. (Also suggested by another recent V case).

And if the residents don't have anyone helping them cover their bases, they might be "innocent" - but it's much more questionable whether those above them are or not.

6 hours ago, LilPeanut said:

There's not a good, logical, reason to cover this up. They reported it to the BoN, the left a huge paper trail, all of that points to a lack of incident report as being an oversight, not a intended action.

Of course there is - are you kidding me? The same reason any of these places do anything! Reputation and damage control!! You report the nurse, report that she has been terminated (for "not following 5 Rights" - not for "killing someone with vecuronium"), and hope the rest doesn't catch up with you. At least not until you have time to clean up the scene a bit.

The "huge paper trail" is pretty spotty if it doesn't even include informing the ME.

Or knowing what happened with an incident report.

Or informing the regulatory agency.

Please. You are reaching here.

3
Up Vote Up Vote ×
Specializes in Pediatrics, Pediatric Float, PICU, NICU.

Wow.

Wow.

After reading through the TBI, I am somehow even more shocked at the absolute negligence and recklessness of RV. The syringe wasn't even labeled with the medication, it just looks like a normal saline flush syringe with a needle attached to it. The first few pages pretty much take away any defense that she could ever possibly have. I'm just shocked.

ETA: The TBI report looks like it could have been written by Wuzzie because Wuzzie pointed out every single step of the incident like it is listed in the report lol

6
Up Vote Up Vote ×

Its unfortunate to me that the name of this nurse only is on the front page of this somewhat popular thread, no one else, not even the facility.

As one article points out what the nurse did was unintentional. What happened after that? Read on. I believe its the scripps link someone posted or hospital watch dog. Check it out fully.

Then I read the family didn't even know about the mistaken paralytic given accidently until almost a year later.

The woman had been out Christmas shopping on the 24th.

Up Vote Up Vote ×
3 minutes ago, wondern said:

Its unfortunate to me that the name of this nurse only is on the front page of this somewhat popular thread, no one else, not even the facility.

As one article points out what the nurse did was unintentional. What happened after that? Read on. I believe its the scripps link someone posted or hospital watch dog. Check it out fully.

Then I read the family didn't even know about the mistaken paralytic given accidently until almost a year later.

The woman had been out Christmas shopping on the 24th.

You tend to get famous when you kill people with an astounding degree of stupidity, hubris, and not a small amount of negligence.

Someone died. Its unfortunate to me that you didn't mention Charlene, the victim who would have lived if her nurse gave even the smallest care.

12
Up Vote Up Vote ×

Charlene Murphey with an e. You feel better now?

Up Vote Up Vote ×

You think it’s okay Charlene Murpheys family was told she died of natural causes for almost a year when they found out from the media on the news otherwise. Was that unintentional?

Up Vote Up Vote ×
15 minutes ago, wondern said:

You think it’s okay Charlene Murpheys family was told she died of natural causes for almost a year when they found out from the media on the news otherwise. Was that unintentional?

Wonder, I don’t think anybody thinks it’s okay but it’s a separate issue. Withholding the information was slimy for sure but it did not kill the patient.

3
Up Vote Up Vote ×
Specializes in Medsurg.
8 hours ago, Jory said:

Oh, there is no doubt in my mind that RV is reading what is online about her.

I am actually curious if she is reading this. Im pretty sure she is

Up Vote Up Vote ×
+ Join the Discussion