Latest on RaDonda Vaught case

Jory, MSN, APRN, CNM · Apr 9, 2019

9 hours 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.

This is why root cause analysis is important. We were discussing the RV case the other day waiting for a meeting to start....it began with a discussion about the mess at Vanderbilt and then we were discussing this case.

Multidisciplinary team. Many team members could remember patients that were harmed, even killed, through true medical errors...but nobody could remember a single one where a nurse had purposely skipped multiple steps that had any one of them been heeded...it could have prevented a patient from experiencing harm/death.

That is why RV is being charged.

Wuzzie · Apr 9, 2019

5 hours ago, wondern said:
What??? That makes no sense at all! Radiology is intended to take xrays and take care of patients in their dept. including sedated patients. A radiology dept. as big as Vanderbilts needs their own nurses! Every floor nurse cannot accompany her pt. to radiology. Give me a break!
To even say that after all we've just heard makes no sense. Things need to change there.
It's actually the easy way out to hold solely accountable only the nurse even if she was the one giving the med. There were other contributing factors that could be improved certainly. How can anyone deny that?

Every patient does not need to be accompanied by a nurse. Those that do should be accompanied by nurses who are familiar with their disease process and the type of care they require. It would be impossible for the radiology nurses to be trained in every disease and the related care required. Also, you keep speaking of other contributing factors. Most of those have been shot down by RV herself. What factors are you referring to.

4 hours ago, wondern said:
If you have hundreds of patients go through your department daily it makes excellent sense.

No, it really doesn't. See above.

4 hours ago, wondern said:
It's probably common sense actually!

Again, common sense dictates that the person best trained to care for a patient should be the one providing that care.

4 hours ago, wondern said:
Hopefully even an anesthesiologist or small team of anesthesiologists on hand as well!

Now you're overreaching. If general anesthesia is being delivered they do have an anesthesia provider there but that really is not too common an occurrence. The vast majority of patients, including Charlene Murphey, do not require that level of care.

Wuzzie · Apr 9, 2019

1 hour ago, Jory said:
Multidisciplinary team. Many team members could remember patients that were harmed, even killed, through true medical errors...but nobody could remember a single one where a nurse had purposely skipped multiple steps that had any one of them been heeded...it could have prevented a patient from experiencing harm/death.

I am baffled why people cannot see that while errors often occur because of a bad system sometimes the system cannot be blamed and the responsibility for the mishap lies solely on the person or people involved. In this case a system with all of the checks and stops and warnings functioned as it should but the person did not and there is no excuse for that.

Wuzzie · Apr 9, 2019

8 hours ago, wondern said:
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?

Nowhere has it been documented that the radiology department was short-staffed. They are staffed by radiology techs who do not monitor or administer medications. Any patient that needs monitoring should have that done by someone who is familiar with the disease process and the care involved. There is no way they could train radiology nurses to be familiar with every single disease and the nursing care required so it makes absolute sense that nurses familiar with the patient and/or their disease be the ones providing the care/monitoring.

8 hours ago, wondern said:
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.

Now it's the orientee's fault? So many ways this could go.

8 hours ago, wondern said:
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?

At 31 years in I'm still learning all kinds of things but by two years I had a firm grasp on the basic concepts of safe medication administration. Heck I had that by the second semester of nursing school. And yes, I would be explaining things to my orientee which begs the question why wasn't RV? What system forced her to chit-chat with Darren rather than focus on the task at hand? Could it be that she was a sub-standard nurse giving sub-standard care and skating by on her popularity?

8 hours ago, wondern said:
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.

The Versed vial label pictured is orange. Your computer may not be accurate.

8 hours ago, wondern said:
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?

Please expand on your thoughts about how this would work. How it would have made a difference given that all other warnings were ignored.

JKL33 · Apr 9, 2019

2 hours ago, Wuzzie said:
Please expand on your thoughts about how this would work. How it would have made a difference given that all other warnings were ignored.

"Huh, that's odd. Well, I guess Versed comes a package that says 'RSI kit' now."

wondern, ASN · Apr 9, 2019

6 hours ago, Wuzzie said:
Nowhere has it been documented that the radiology department was short-staffed. They are staffed by radiology techs who do not monitor or administer medications. Any patient that needs monitoring should have that done by someone who is familiar with the disease process and the care involved. There is no way they could train radiology nurses to be familiar with every single disease and the nursing care required so it makes absolute sense that nurses familiar with the patient and/or their disease be the ones providing the care/monitoring.
So they weren't staffed with nurses at all and now radiology nurses aren't as qualified as floor/unit nurses? They are RN's with the same training as any other RN. They learned the very same human anatomy and physiology systems as we did! They learned their ABC's just like we did. They'd be more familiar probably than some of the nurses accompanying their patient to Xray with the drugs used in their area frequently.
If I read through parts of the 330 page report correctly, Vandy said they were going to staff radiology with RN's in their follow up plan but you still don't think it's necessary?! or makes sense?! It makes absolute sense! So are you saying you don't agree with their own follow up plan of what they feel necessary to prevent future deaths?
Now it's the orientee's fault? So many ways this could go.
I never said it was his fault. I'm curious as to why though wasn't he paying attention to her and what she was doing. What was going on that day on that unit? Orientees could even save lives if they'd pay attention as in this instance. I mean if she's volunteered to orient you and you're going to distract her during medication aministration, pay attention too! Help her out. You're an RN! She's helping you. I wonder if he's in management yet? Just curious, really?
At 31 years in I'm still learning all kinds of things but by two years I had a firm grasp on the basic concepts of safe medication administration. Heck I had that by the second semester of nursing school. And yes, I would be explaining things to my orientee which begs the question why wasn't RV? What system forced her to chit-chat with Darren rather than focus on the task at hand? Could it be that she was a sub-standard nurse giving sub-standard care and skating by on her popularity?
Maybe you are way smarter than the average bear! I was till learning tons at 2 years out of school. If her care was substandard why did Vanderbilt have her as a help all resource nurse?
If that is true abut the popularity thing, Vandy should not allow any employee advantages by allowing anyone to skate by on popularity, that would be discriminatory towards other employees. Would it be her manager that let her skate? Where's their accountability? I guess it is human nature to take care of the people you like so it probably happens everywhere everyday. We as professionals really need our own union to protect us from that kind of discrimination.
The Versed vial label pictured is orange. Your computer may not be accurate.
It's an Apple Macbook Pro. I love it. The lid is orange not the vial. Is that not what yours is showing? I actually did notice in another photo after you pop the top it says paralyzing agent all around the rubber insert part. What's that gray part actually called anyhow? The 'insertion point' maybe? Gasket? Diaphragm? I forget right now.
Please expand on your thoughts about how this would work. How it would have made a difference given that all other warnings were ignored.
Who really knows, Wuzzie, its just a thought that may have helped, just one more step to slow someone down possibly to notice! So why not?!
Vanderbilt is a pretty world-renowned medical center. They have a lot of brilliant people working there, doctors, nurse, therapists, all kinds of really brilliant people, some that worked really hard to get there. They do lots of extraordinarily good things thanks to the good 'hands on patients' people working within. I saw a pediatric surgeon on the Discovery Channel there doing in utero surgeries over almost two decades ago!
She was probably sticking up for her wonderful Vanderbilt when she said they weren't understaffed and/or she was comfortable giving Versed, keeping up appearances on behalf of Vanderbilt before she knew they were going to hang her out to dry. I know its not safe to say you know how to do something then you really don't, but people try to do that sometimes anyhow so they don't appear inexperienced. Vanderbilt knows that and could check skills before assigning a 2 year experienced nurse to work as a resource or help all or whatever she was doing. They could also try harder to take care of their good experienced nurses. They were all over the news about 5 years back laying off hundreds of longtime devoted employees to fix their budget by some $250 million. It was sad. You don't treat devoted long-time employees like that. The patients are the ones who lose, not to mention new nurses missing out on all that great teaching from experienced nurses. Big picture, that's all.
It's easy for us to sit back and say this or that but until we're in those very shoes we just don't know everything that contributed, and it certainly does not hurt anything to discuss the possibilities in order to fully examine how to prevent further deaths. To not look at everything is rather complacent. I'm glad to see they have made a plan to prevent this from happening again hopefully. If their plan includes staffing their very busy radiology department with nurses than I'm all for it!

Wuzzie · Apr 9, 2019

27 minutes ago, wondern said:
They are RN's with the same training as any other RN. They learned the very same human anatomy and physiology systems as we did! They learned their ABC's just like we did. They'd be more familiar probably than some of the nurses accompanying their patient to Xray with the drugs used in their area frequently.

So, if I'm understanding you correctly you are saying nurses are generally interchangeable and should be able to care for any patient on any unit at any time because they've passed A&P and CPR. Yet, I recall you being upset when you thought RV was being floated to all kinds of units where she didn't have any experience.

27 minutes ago, wondern said:
Who really knows, Wuzzie, its just a thought that may have helped, just one more step to slow someone down possibly to notice! So why not?!

Because the first 20 or so steps she blew by were not enough?

27 minutes ago, wondern said:
I know its not safe to say you know how to do something then you really don't, but people try to do that sometimes anyhow so they don't appear inexperienced.

You know what we call that? Hubris. Not a good trait in anyone.

wondern, ASN · Apr 9, 2019

Two years experience is not enough to be floating everywhere with paralyzers in your pocket especially yes.

I agree hubris is not a good trait. No argument here.

One of the things I dislike the most about nursing is it seems like a lot of nurses are riding up on their high horse acting as if they are smarter than anyone else instead of trying to work together or collaborate. There's always a few out there trying to look like they have all the answers and only their way is the right way. There are a lot of ways to look at things.

Wuzzie · Apr 9, 2019

28 minutes ago, wondern said:
o are you saying you don't agree with their own follow up plan of what they feel necessary to prevent future deaths?

No I am not saying that at all.

Wuzzie · Apr 9, 2019

1 minute ago, wondern said:
One of the things I dislike the most about nursing is it seems like a lot of nurses are riding up on their high horse acting as if they are smarter than anyone else instead of trying to work together or collaborate. There's always a few out there trying to look like they have all the answers and only their way is the right way. There are a lot of ways to look at things.

Are you insinuating that about me? If you are please tell me how that adds to the discussion?

wondern, ASN · Apr 9, 2019

What discussion? You're twisting words. Not to mention now even exaggerating the 20 steps she missed!

Yes she made a mistake. Others were involved whether you like it or not.

Wuzzie · Apr 9, 2019

8 minutes ago, wondern said:
What discussion? You're twisting words. Not to mention now even exaggerating the 20 steps she missed!

I'm hardly twisting words when I'm directly quoting you. Exaggerrating? There were screens and warnings that were outlined in the TBI report in addition to the 12 things reported in the CMS report. So, no I'm not exaggerating. And nobody else made her practice nursing in such a sloppy manner.

Also, you didn't answer my question.