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]

4 hours ago, Coffee Nurse said:

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 had to look it up too! But then the air is a little thin up here on my high horse! ?

[TriciaJ, RN]

2 hours 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.

You make some fair points, but what are you calling scorn and contempt? No one here has called for prison time or voiced the desire for misfortune for this nurse. No one has cast aspersions on her character; we don't know her character. We just find her actions unfathomable and hopefully more information comes out that clarifies things.

But at this point what do you think is the appropriate course of action by the powers-that-be? Do you think there should be no consequences? No remediation of any sort?

For those who think criminal charges inappropriate, fair enough. But what do you think would be appropriate? Are nurses expected to have any accountability for our own actions? What does that accountability look like?

We've argued the pros and cons of the current situation ad nauseum. In an ideal world, what happens next?

[Tenebrae, BSN, RN]

8 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.

Or perhaps nurses could read the label

[dumbnurse, ASN, BSN, MSN, LPN]

Probably not many employment opportunities for her out there. She's lucky the family is not pursuing litigation. I'd have to be on suicide watch after all that.

[LilPeanut, MSN, RN, NP]

On 4/9/2019 at 12:57 PM, AnnieNP said:

Medscape for nurses now has this on their website. I apologize if this has already been posted

https://www.medscape.com/viewarticle/911109?nlid=129198_5163&src=WNL_mdplsfeat_190409_mscpedit_diab&uac=88928EG&spon=22&impID=1932082&faf=1

So, my biggest issue with that article is that it equates all rule breaking as being equal in severity, risk and consequence. Going 10 MPH vs 50 mph over the speed limit for example, as cited in the article. Speeding isn't a great idea. Most of us know it, but many do it anyway LOL But, it is intellectually dishonest to say it is the same that you were going 55 in a 45 zone and 95 in a 45 zone.

One is not a great idea, one is far more dangerous and more associated with accidents and harm.

I remember when I was a kid and got a speeding ticket, there was a range of fines, depending on how fast above the limit you were going, because the faster you were going, the more dangerous.

I mean, with this author's logic, there's no different in driving 160 mph down the street and driving 20 mph through a parking lot.

RV was driving 150 mph in a school zone

On 4/9/2019 at 5:07 PM, 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.

Please list the systems fault, that RV did not purposefully override or ignore.

They have systemic safety measures. One of the biggest faults found in the CMS that I saw was that they had an incompetent nurse. It was worded in a fancy way, but that's what it said.

Eventually, enough is enough. You have a reasonable amount of safety and well educated professionals, and there you go. There is no reason to think that another stumbling block would have slowed her down.

6 hours ago, dumbnurse said:

Probably not many employment opportunities for her out there. She's lucky the family is not pursuing litigation. I'd have to be on suicide watch after all that.

She has a job currently, she immediately got hired somewhere else.

[hppygr8ful, ASN, RN, EMT-I]

Well she goes to court tomorrow and the whole nursing world waits with baited breath...…..

[Nursetom1963, BSN]

As horrified as I was reading this, I can almost see myself doing this, I have close calls every day; and the computerization is more hurt than help where I work. What can we learn from this?

[LilPeanut, MSN, RN, NP]

1 hour ago, Nursetom1963 said:

As horrified as I was reading this, I can almost see myself doing this, I have close calls every day; and the computerization is more hurt than help where I work. What can we learn from this?

Why do you think you are having close calls every day? What can you do about yourself as well to augment the computer systems? A necessary part of the computer is the RN who is administering the medication, so don't let yourself be fooled that it is supposed to be doing work for you. Which EMR system do you have? (there are some that are objectively bad, I'll give you)

No one should be having close calls that frequently.

[TriciaJ, RN]

3 hours ago, Nursetom1963 said:

As horrified as I was reading this, I can almost see myself doing this, I have close calls every day; and the computerization is more hurt than help where I work. What can we learn from this?

That computers can be a help or a hindrance, but never a substitute for using your own brain.

Did you see the episode of The Office where Michael was using GPS for the first time? He turned exactly where the voice told him to turn and drove straight into the lake that was plainly visible. He trusted the technology more than his own eyeballs.

[hppygr8ful, ASN, RN, EMT-I]

7 hours ago, LilPeanut said:

Why do you think you are having close calls every day? What can you do about yourself as well to augment the computer systems? A necessary part of the computer is the RN who is administering the medication, so don't let yourself be fooled that it is supposed to be doing work for you. Which EMR system do you have? (there are some that are objectively bad, I'll give you)

No one should be having close calls that frequently.

I agree. A person is who is having near miss med errors daily needs to look their own practice and make improvements to be more competent.

Hppy

[RNNPICU, BSN, RN]

9 hours ago, Nursetom1963 said:

As horrified as I was reading this, I can almost see myself doing this, I have close calls every day; and the computerization is more hurt than help where I work. What can we learn from this?

Nursetom1963:

Please check your practice. If you are having close calls everyday, Stop, think about what you are doing before you act on an action. Think about what your plan is. Blazing ahead and realizing you are having close calls EVERY DAY, is a sign that you need to slow down. Slowing down means taking that extra second or two, read, take a deep breath, even close your eyes for two seconds, think about what you are going to do before you do it. If you keep your near misses up everyday you will make a mistake and possible a fatal one.

The biggest thing we can learn from this is to not operate on autopilate, think about our actions and how serious our job is, and to not just blaze on forward.

[Here.I.Stand, BSN, RN]

11 hours ago, Nursetom1963 said:

As horrified as I was reading this, I can almost see myself doing this, I have close calls every day; and the computerization is more hurt than help where I work. What can we learn from this?

That our instructors didn’t drill down those 5 Rights to hear themselves talk.