Latest on RaDonda Vaught case

Coffee Nurse, BSN, RN · Apr 9, 2019

2 hours ago, wondern said:
If someone wants to label someone or their thinking at least they could do it in English! Bully! or not play games...watch me trick her with another language that includes 'Ignora' in its spelling. How clever!

So you encounter something you're unfamiliar with, and rather than doing even a bit of superficial research (seriously, a five-second Google search told me what "ignoratio elenchi" means), you proceed full-steam ahead on the strength of your own assumptions.

I think I see why you're defending RV.

TriciaJ, RN · Apr 9, 2019

42 minutes ago, Wuzzie said:
If the multiple warnings on the Accudose didn’t stop her why would words on a vial she didn’t read make a difference?

And then there'd be too many words on the vial. It's too confusing to have so many words. Of course you're not going to bother to read a vial that's teeming with words.

Honestly, this latest turn is just making me laugh. Take a break, Wuzzie. You've done your best.

Coffee Nurse, BSN, RN · Apr 9, 2019

48 minutes ago, Wuzzie said:
Then it’s a good thing a layperson wouldn’t be giving it.
Seriously, I looked at an actual vial and it’s orange. Regardless this is the most asinine debate I’ve ever had with another professional so before I kill any more brain cells on it I’m out.

Anyone else getting shades of this?

It's a good thing, isn't it, that nurses aren't kindergarteners who don't know any more than "red means stop."

Wuzzie · Apr 9, 2019

12 minutes ago, TriciaJ said:
Honestly, this latest turn is just making me laugh. Take a break, Wuzzie. You've done your best.

It got a little surreal didn’t it. ?

MunoRN, RN · Apr 10, 2019

18 hours ago, LilPeanut said:
Because I agree that many if not even most errors are systems issues. But that does not mean every error is. Everything occurred perfectly up to her involvement. If she had used the systems, her involvement would not have killed the patient.
People want to make the system so infallible that it is impossible to make a mistake - that is not going to happen, and if it does, they will get rid of nurses. If there's a system that makes it so fool proof to give a medication that you do not have to be competent or careful or educated to administer it, then non licensed personnel can administer meds.

There were a number of faults in the system and processes where had those faults not occurred the error would have been avoided, likewise there were a number of errors in the nurses practice which had they not occurred the errors would have been avoided. I get the desire to direct scorn and contempt towards RVs actions, but I don't agree that it's worth ignoring the importance of systemic safety measures to accentuate RV's guilt.

Some examples, the use of trade names in MARs was recommended to be a forbidden practice more than a decade ago by the ISMP, had the order been properly written as "midazolam" the error would have been avoided. The use of predictive text starting with the first letter is a well recognized safety issue and can be mitigated by extending the number of characters required before predictive text activates, this was not in use at Vanderbilt. All ADC manufacturers provide the option of having an alert go immediately to the pharmacist when a high alert drug is overridden to confirm that it was the correct drug, this was not used. Despite the known safety issues associated with partial BCMA implementation, Vandy chose not make BCMA available in their imaging department. There were also communication failures, both RV and the patient's primary nurse failed to notify the imaging nurse that the patient would be receiving sedation / anxiolysis in the imaging department, even though the primary nurse was aware the imaging nurse did not think the patient would be receiving any medication that would indicate the need for any monitoring.

I agree that ideal nursing practice shouldn't require the assistance of other safeguards to keep patients safe, I disagree that we should allow fatal errors to occur to drive this point home.

wondern, ASN · Apr 10, 2019

25 minutes ago, MunoRN said:
There were a number of faults in the system and processes where had those faults not occurred the error would have been avoided, likewise there were a number of errors in the nurses practice which had they not occurred the errors would have been avoided. I get the desire to direct scorn and contempt towards RVs actions, but I don't agree that it's worth ignoring the importance of systemic safety measures to accentuate RV's guilt.
Some examples, the use of trade names in MARs was recommended to be a forbidden practice more than a decade ago by the ISMP, had the order been properly written as "midazolam" the error would have been avoided. The use of predictive text starting with the first letter is a well recognized safety issue and can be mitigated by extending the number of characters required before predictive text activates, this was not in use at Vanderbilt. All ADC manufacturers provide the option of having an alert go immediately to the pharmacist when a high alert drug is overridden to confirm that it was the correct drug, this was not used. Despite the known safety issues associated with partial BCMA implementation, Vandy chose not make BCMA available in their imaging department. There were also communication failures, both RV and the patient's primary nurse failed to notify the imaging nurse that the patient would be receiving sedation / anxiolysis in the imaging department, even though the primary nurse was aware the imaging nurse did not think the patient would be receiving any medication that would indicate the need for any monitoring.
I agree that ideal nursing practice shouldn't require the assistance of other safeguards to keep patients safe, I disagree that we should allow fatal errors to occur to drive this point home.

Amen! You are very good with your words, and I appreciate you sharing your knowledge and expertise in such a gracious, kind, and intelligent manner. Thank you, MunoRN.

klone, MSN, RN · Apr 10, 2019

5 hours ago, wondern said:
The lid is orange. The label looks red to me on my computer, anyone else?

The dress is purple and black!!

klone, MSN, RN · Apr 10, 2019

Wondern, you've jumped the shark. Just...stop.

klone, MSN, RN · Apr 10, 2019

5 hours ago, wondern said:
Maybe something on the bottles could be improved. Like in addition to saying Paralyzing Agent, STOPS BREATHING-Ambubag or Vent required. I mean really spell it out.

Are you ***ing serious?

klone, MSN, RN · Apr 10, 2019

3 hours ago, Coffee Nurse said:
Anyone else getting shades of this?
It's a good thing, isn't it, that nurses aren't kindergarteners who don't know any more than "red means stop."

OMG, I JUST posted that below!

Luchador, CNA, EMT-B · Apr 10, 2019

2 minutes ago, klone said:
Are you ***ing serious?

I asked her the same thing. Two semesters of A&P, two semesters of pharmacology, semesters of med-surge and advanced med surge, at least, for her to get a BSN and somehow RV didn't know that a P A R A L Y T I C stops breathing.

Wuzzie · Apr 10, 2019

57 minutes ago, MunoRN said:
I get the desire to direct scorn and contempt towards RVs actions, but I don't agree that it's worth ignoring the importance of systemic safety measures to accentuate RV's guilt.

I absolutely agree that systemic safety measures are important but don’t believe they should supersede critical thinking and good nursing judgment. There were just so many safety measures in place that RV ignored it’s hard to see what the value of any more would have been in this situation. Would she have blown past those too? Based on her actions I believe so. And just to be clear, I am more frustrated than anything at the perpetuation of this idea that someone could act in such a negligent manner and yet get a pass simply because she’s a nurse. I find the whitewashing that is occurring appalling. I’m really not an ogre. There was another med error discussed on this forum with a mix up between Cardene and Cardizem. The patient coded and although they achieved ROSC it’s hard to say what the long term sequelae of that code will be for the patient. In that situation, even if the patient had died, I wouldn’t have supported criminal charges because of the extremely clear system errors that doomed that nurse from the start. This case is very, very different. The actual override is the least of the issues as far as I’m concerned. The override function is a necessary evil because of the limitations of the various systems. But even overrides can be safely done if we practice our due diligence. I think the public deserves nurses who are conscientious in their practice. I find it hard to fathom that RV would, in a blink of an eye, go from being a nurse who practiced safely to one who so egregiously ignored every single actual warning sign and her own confusion about the need to reconstitute a med she knew didn’t need to be reconstituted. She seems to lack some sort of internal alarm system which makes her extremely dangerous.

Regardless of what some people here might think I am not reveling in what is happening to RV. I just believe it’s necessary in the interest of public safety. We must at all times be aware that our actions, as nurses, have the potential to harm or even kill another human being and practice with patient safety as our highest goal. We all know that hospitals don’t make that easy for us but we, alone, are responsible for the care we deliver.

The arguments from both sides have been passionate for sure but If nothing else, this case and the ensuing discussions have likely caused each and every one of us to examine our own practice for deficiencies that might result in harm to another human being.

Muno, I do appreciate that you and I can discuss this without ad hominem attacks and thinly veiled snark. We can disagree agreeably and in the end learn from each other.