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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!

26 minutes ago, wondern said:

Stop blaming the nurse for the entire thing! She feels bad enough I'm sure.

 No culpability on Vanderbilts part before the fact though? None? Really?

 They used her as a 'Resource Nurse', TriciaJ. Was that okay? Obviously not.

But Wonder she was responsible for the whole thing. She ignored every safety measure that was put in place by the hospital and didn’t follow any of the standards of safe medication administration that even a first year nursing student understands. What did after is an entirely separate issue. As far as her being a resource or help-all nurse. Basically it’s just an unassigned nurse who is free to help with tasks. Someone with 2 years experience is more than qualified to fill this role. She also said she was familiar and comfortable with giving Versed but look at the difference...

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1 Votes

Wuzzie, I respectfully disagree. I don't think it was all her fault.

It's a tragic event made even worse by increasing a lack of trust to her survivors and to the general public with the lack of transparency. It makes me wonder what we haven't found out about really. Think about it.

I hope her family was given the opportunity to tell her goodbye. Did anyone hear if that was made possible?

1 Votes

And I understand you are being respectful but you really must read both the CMS and the TBI report. This was not a new grad but a nurse with two years of experience and a certification. I know the issue of ’s response is really sticking in your craw but that is a separate issue and had nothing to do with what caused the patient’s death. We are bound by a code of standards that she deviated from multiple times and in the worst possible way for no apparent reason.

5 Votes
16 minutes ago, Wuzzie said:

But Wonder she was responsible for the whole thing. She ignored every safety measure that was put in place by the hospital and didn’t follow any of the standards of safe medication administration that even a first year nursing student understands. What Vandy did after is an entirely separate issue. As far as her being a resource or help-all nurse. Basically it’s just an unassigned nurse who is free to help with tasks. Someone with 2 years experience is more than qualified to fill this role. She also said she was familiar and comfortable with giving Versed but look at the difference...

F11DB2E6-8D8E-4C56-8576-9472294BC6DB.jpeg 6B8CE348-6BBE-4A09-9BAF-097FE8E6964D.jpeg

Obviously someone with only 2 years of experience is not all that qualified to be a resource nurse and floating to different critical areas in the hospital that are short staffed even if her area wasn't. I never said what she did was ok, and it sounds as if she knew she made a possibly deadly mistake as well rather quickly.

Are you suggesting it is just fine for them to keep sending new nurses basically on to other short-staffed critical areas? Just keep up the good work? I think more experienced nurses should be granted the jobs named 'Resource Nurse".

1 Votes
Specializes in Pediatrics, Pediatric Float, PICU, NICU.
2 minutes ago, wondern said:

Obviously someone with only 2 years of experience is not all that qualified to be a resource nurse and floating to different critical areas in the hospital that are short staffed even if her area wasn't. I never said what she did was ok, and it sounds as if she knew she made a possibly deadly mistake as well.

Are you suggesting it is just fine for them to keep sending new nurses basically on to other short-staffed critical areas? Just keep up the good work? I think more experienced nurses should be granted the jobs named 'Resource Nurse".

They weren’t short staffed. She directly admitted this herself. In fact the Help All Nurse is only when they have an abundance of staff. This nurse also isn’t floating to other units in the traditional sense where she would have a full assignment on another unit. She is helping the other nurses with whatever they would need.

4 Votes
11 minutes ago, wondern said:

Obviously someone with only 2 years of experience is not all that qualified to be a resource nurse and floating to different critical areas in the hospital that are short staffed even if her area wasn't. I never said what she did was ok, and it sounds as if she knew she made a possibly deadly mistake as well. 

 Are you suggesting it is just fine for them to keep sending new nurses basically on to other short-staffed critical areas? Just keep up the good work? I think more experienced nurses should be granted the jobs named 'Resource Nurse". 

I think you have a misunderstanding of the situation. She wasn’t being sent to different critical care units. She was only helping in the Neuro ICU where she was already a staff member! She was an extra nurse. She had been there for two years! By that time she would be familiar with the needs of those types of patients and the care provided to them. All she was doing was being an extra hand. Nowhere does it state that she was being relied on for anything more than helping to complete tasks. We have the same position but we call it a float nurse which is an unassigned nurse who covers breaks and assists when an extra hand is needed on the same unit they already work. The senior staff act as true resource nurses. As in the people we go to when the poop hits the fan.

4 Votes
Specializes in NICU/Neonatal transport.
3 hours 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?

They were informed at the time that they thought she might have been given a medication made her stop breathing. They were not told specifically what medication.

From https://www.tennessean.com/story/news/health/2019/02/04/vanderbilt-deadly-vecuronium-error-victim-would-forgive-nurse-son-says/2774381002/

Quote

...Eventually, a doctor told them that it appeared Murphey had been given too much medication or possibly the wrong medication....

...The next day, a Vanderbilt official confirmed to Murphey’s family that she was given the wrong medication, which caused her to stop breathing during the scan, Gary said. The one thing that Vanderbilt didn’t tell them was what drug Murphey had received by mistake.

The family found that out about a year later, when they saw a story on the news. The drug was vecuronium, a powerful paralyzer that is used to hold patients still during surgery.....

53 minutes ago, canoehead said:

In the August 2016 ISMP Nurse ERR newsletter they talk about ten similar cases. Some just as careless as this one, but none of those people were charged. I don't think she used appropriate care, but she is definitely being used as an example.

Actually, I believe what you are referring to are similar cases where people were charged.

14 minutes ago, wondern said:

Wuzzie, I respectfully disagree. I don't think it was all her fault.

It's a tragic event made even worse by increasing a lack of trust to her survivors and to the general public with the lack of transparency. It makes me wonder what we haven't found out about really. Think about it.

I hope her family was given the opportunity to tell her goodbye. Did anyone hear if that was made possible?

Of course, if you read anything about the case, she was on support for 2 days after the event.

1 minute ago, wondern said:

Obviously someone with only 2 years of experience is not all that qualified to be a resource nurse and floating to different critical areas in the hospital that are short staffed even if her area wasn't. I never said what she did was ok, and it sounds as if she knew she made a possibly deadly mistake as well.

Are you suggesting it is just fine for them to keep sending new nurses basically on to other short-staffed critical areas? Just keep up the good work? I think more experienced nurses should be granted the jobs named 'Resource Nurse".

She was on her home unit, not being floated to another unit. She was a critical care nurse. She obviously wasn't a very good one. That's the whole issue.

4 Votes
Specializes in Psych, Corrections, Med-Surg, Ambulatory.
8 minutes ago, wondern said:

Are you suggesting it is just fine for them to keep sending new nurses basically on to other short-staffed critical areas? Just keep up the good work? I think more experienced nurses should be granted the jobs named 'Resource Nurse".

She wasn't new. I never saw the title "resource nurse"; I only saw "help-all nurse". It was defined as a super-numerary nurse who did not take an assignment, only helped out with tasks. She did not float to other units.

I've read the CMS and TBI reports in their entirety. I can't find anything that puts any onus on for the med error.

2 Votes
Specializes in Critical Care.
33 minutes ago, Wuzzie said:

But Wonder she was responsible for the whole thing. She ignored every safety measure that was put in place by the hospital and didn’t follow any of the standards of safe medication administration that even a first year nursing student understands. What Vandy did after is an entirely separate issue. As far as her being a resource or help-all nurse. Basically it’s just an unassigned nurse who is free to help with tasks. Someone with 2 years experience is more than qualified to fill this role. She also said she was familiar and comfortable with giving Versed but look at the difference...

While it's certainly true that she could have prevented this from happening all by herself, and that she committed an impressive string of errors, what I don't get about your point of view on this is that preventing errors should be up to just one person. Part of my job involves implementing systems and processes that make it really difficult for errors to end up harming a patient, and many of my biggest barriers to making that happen are reflected in many of your (and others') arguments on this case.

Specializes in NICU/Neonatal transport.
1 minute ago, MunoRN said:

While it's certainly true that she could have prevented this from happening all by herself, and that she committed an impressive string of errors, what I don't get about your point of view on this is that preventing errors should be up to just one person. Part of my job involves implementing systems and processes that make it really difficult for errors to end up harming a patient, and many of my biggest barriers to making that happen are reflected in many of your arguments on this case.

The right med was ordered and profiled.

They were not understaffed.

At some point, it is up to an individual to be competent. One of the parts of having a safe system is having people who can practice safely.

4 Votes
2 minutes ago, MunoRN said:

While it's certainly true that she could have prevented this from happening all by herself, and that she committed an impressive string of errors, what I don't get about your point of view on this is that preventing errors should be up to just one person.

Where did I say that? There were multiple warnings in place by both the hospital’s Accudose as well as the manufacturer’s packaging. At what point does personal accountability play a role when someone chooses to blow through every single safe guard put in place?

1 Votes
9 minutes ago, MunoRN said:

  Part of my job involves implementing systems and processes that make it really difficult for errors to end up harming a patient, and many of my biggest barriers to making that happen are reflected in many of your arguments on this case.

Please explain how my viewpoint that nurses should be accountable for their practice presents obstacles to implementing patient safety systems.

What I find quite ironic is that in the same thread we have complaints that there were not enough warnings to prevent the incident until that was proven to not be true so the tactics got switched to there being too many warnings resulting in “alarm fatigue”.

3 Votes
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