Latest on RaDonda Vaught case

[Emergent]

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!

[Wuzzie]

26 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,

Also wanted to add the systems and processes you are describing were never meant to replace critical thinking, good nursing judgement and adherence to accepted standards.

Your processes are only good if people actually follow them. You get a rogue nurse like RV and no system anywhere is going to stop her from harming a patient.

I have said before I am an innate rule-follower which means I work the systems and processes as I am told to do. I am quite unsure how I am a barrier.

[MunoRN, RN]

51 minutes ago, LilPeanut said:

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.

I get that, is the issue with acknowledging that this could have also been avoided on a system and process level that you see it as absolving the nurse of her string of errors?

[MunoRN, RN]

53 minutes ago, Wuzzie said:

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?

I'm not sure where your getting that anybody is arguing personal accountability doesn't play a role, the issue is whether personal accountability should be the only role that prevents harm to patients.

[Wuzzie]

4 minutes ago, MunoRN said:

I'm not sure where your getting that anybody is arguing personal accountability doesn't play a role, the issue is whether personal accountability should be the only role that prevents harm to patients. 

Muno she ignored the process that was in place to protect the patient. Once that happened all that was left was her personal accountability.

[MunoRN, RN]

42 minutes ago, Wuzzie said:

Also wanted to add the systems and processes you are describing were never meant to replace critical thinking, good nursing judgement and adherence to accepted standards.

Your processes are only good if people actually follow them. You get a rogue nurse like RV and no system anywhere is going to stop her from harming a patient.

I have said before I am an innate rule-follower which means I work the systems and processes as I am told to do. I am quite unsure how I am a barrier.

One of my biggest challenges is convincing administrators, managers, etc that a set of circumstances that kills or harms someone shouldn't be allowed hinge on just the actions of a single person. When a surprising number of staff nurses argue that we really should look at these events as just being the responsibility of one person, it leaves me less able to protect these types of events from happening in the future.

The RV case in particular is a bit of deja-vu. I worked at a facility that was opposed to implementing barcode scanning in procedural areas (such as imaging) even though it's known that a partial implantation of BCMA is dangerous. They felt comfortable in their justification of this because there were plenty of nurses who had a similar view to yours; so long as ideal practice is used there's no need for BCMA. I was only there for about a year after that, but in that time there were two sentinel events in the imaging department due to medication errors that would not have occurred if BCMA was available.

Ideally, all nurses are strict rule followers like yourself, unfortunately, outside of NICUs and some other isolated environments, strict rule followers are quickly gotten rid of as "not a good fit" for the job.

[wondern, ASN]

39 minutes ago, MunoRN said:

I'm not sure where your getting that anybody is arguing personal accountability doesn't play a role, the issue is whether personal accountability should be the only role that prevents harm to patients.

Thanks, MunoRN. We're all in this thing together. ????

[Wuzzie]

20 minutes ago, MunoRN said:

They felt comfortable in their justification of this because there were plenty of nurses who had a similar view to yours; so long as ideal practice is used there's no need for BCMA.

But, I never, ever said that!! You are putting words in my mouth. BCMA was never meant to replace the 5 rights it was meant to be an adjunct to them. I will admit that some people use it as a means to be less than dilligent but I see its value if it is used in conjunction with accepted practice standards. But that doesn’t change the fact that if a lazy nurse overrides the BCMA if he/she does the 5 rights the patient then an error won’t be made. The 5 rights when actually done are failure proof. But if the same nurse doesn’t do either then all bets are off.

Also, it should be noted that BCMA only works for unit doses and it can be overridden. The only way it would come close to being as good a system as the 5 rights would be if the override function was taken away.

[Susie2310]

12 minutes ago, MunoRN said:

I worked at a facility that was opposed to implementing barcode scanning in procedural areas (such as imaging) even though it's known that a partial implantation of BCMA is dangerous. They felt comfortable in their justification of this because there were plenty of nurses who had a similar view to yours; so long as ideal practice is used there's no need for BCMA. I was only there for about a year after that, but in that time there were two sentinel events in the imaging department due to medication errors that would not have occurred if BCMA was available.

I don't believe that Wuzzie or others were arguing that barcode scanning has no value in safe medication administration. Using one's critical thinking, i.e. the Five Rights of Safe Medication Administration and other medication administration safety checks, are paramount to administering medications safely. A barcode scanner does not replace a nurse's critical thinking. Use of the Five Rights and other medication safety checks are not rendered unnecessary by the practice of barcode scanning.

[Wuzzie]

52 minutes ago, MunoRN said:

the issue is whether personal accountability should be the only role that prevents harm to patients. 

I never said it was the only role but when every other process is completely ignored it might be the last hope for preventing harm.

[wondern, ASN]

Thanks, MunoRN for also sharing what happened in another radiology department where 2 deaths happened in a year over medication administration issues. It takes guts to share some of the stuff we'd really rather not remember. Thank you.

All of the environmental issues need to be addressed as well. What led up to it? How could it have been prevented? Is there anything we can do to improve?

Wuzzie, if radiology wasn't short-staffed why was she called down from NeuroICU? Because radiology didn't have the staff to monitor her? That to me is short staffed. It was in the Radiology department, not in the well-staffed Neuro ICU, where the incident occurred, correct? That's my point. Why wasn't she up there 'helping all', taking the time to show her orientee how she was reconstituting the accidental wrong med and all. Instead the orientee distracted her during the process. Maybe that's a difference in a 2 year experience nurse and one that is more of a true resource person. To me at 2 years I'm still learning all kinds of new things. Wouldn't you be explaining what you were doing to your orientee?

Also, not an excuse but just a fact...the Versed bottle pictured has a lot more red on the label than the paralytic. I realize reading is a requirement as well.

I like the idea of having it in a kit like someone else posted they do in their ER, not that that absolves us from reading but still anything to help prevent more accidents. Do y'all like that idea?

[Emergent, RN]

I'm wondering , does BCMA reliance program the brain to be less reliant on the simpler system of looking at the MAR, checking the med and making sure the 5 rights are right?

The steps required to accomplish BCMA are distracting to the brain. I do believe, with these well intentioned new systems, human neuro functioning has not been considered.

[TriciaJ, RN]

1 hour ago, Emergent said:

I'm wondering , does BCMA reliance program the brain to be less reliant on the simpler system of looking at the MAR, checking the med and making sure the 5 rights are right?

The steps required to accomplish BCMA are distracting to the brain. I do believe, with these well intentioned new systems, human neuro functioning has not been considered.

I wonder about that too. When I started out, I had to medicate a whole ward full of patients using stock meds and the tray with the slots and holes for the cards and cups. Those were med errors waiting to happen.

I thought unit dose was nothing short of miraculous. Then came the Pyxis machine. Bar code was even better. It was like having an extra pair of eyeballs protecting me. But I never saw any of it as a reason to not use my own eyeballs and my own brain. Maybe because I saw the glitches in the systems while they were getting up and running. The technology was only as good as the people programming it, and the people using it.

I wonder if the current generation is used to trusting technology more than their own brains. People keep saying how Vandy should have had a better system in place to prevent this. For the love of Pete, how? What do you do to foolproof the system from someone who blows past all the protocols?