Latest on RaDonda Vaught case

RobbiRN, RN · Apr 8, 2019

I'm late to the party -- again. Maybe this was covered in a previous thread, but what can we learn from the actual incident? To me, the biggest mistake was after all the others discussed in this thread. A paralytic (vecuronium) doesn't kill a patient. Failure to to bag or vent a paralyzed patient will result in death within a few minutes. Supposedly, after the vecuronium was given, the patient was put into the scanning machine, and left alone for thirty minutes. Didn't anyone watch for a minute or two to see what the drug would do before shoving the patient into the MRI tube? Paralytics usually hit in a matter of seconds. Versed also can require mechanical support in some patients. Was the need for speed so important that we couldn't wait a couple of minutes to observe a med effect?

Wuzzie · Apr 8, 2019

3 hours ago, wondern said:
Maybe a paralyzing agent doesn't need to be put in a suremed or pyxis or whatever. Maybe only anesthesia people need to have it.

In the ICU setting immediate access to these drugs is necessary. They are not only used by anesthesia they have other uses that are clinically necessary. Keeping them in an RSI box would mean the boxes would be used for something they weren’t originally intended and could lead to the lack of availability should an emergency arise.

Wuzzie · Apr 8, 2019

2 minutes ago, RobbiRN said:
Supposedly, after the vecuronium was given, the patient was put into the scanning machine, and left alone for thirty minutes. Didn't anyone watch for a minute or two to see what the drug would do before shoving the patient into the MRI tube?

The patient was not put in the scanner she was in a holding area while the contrast ( may not be the correct term) circulated. She was found unresponsive when they went to get her for the scan. But you’re absolutely right. The nurse who gave the medication should have observed her for at least a few minutes after to see if there were any adverse affects. This has been my biggest bone of contention all along.

TriciaJ, RN · Apr 8, 2019

1 hour ago, Dsmcrn said:
Umm the date on this document by the signatures is the beginning of December.. To my knowledge no charges were filed until 2 months later. Is this sufficient for you TriciaJ?

No, because how do we know what she realized, when? She did initial a waiver to have an attorney present. When you're being interviewed by law enforcement about a patient death it's not out of the realm of possibilities that charges may come about. Many people on this site question if they should retain legal counsel on all manner of employment issues.

Dsmcrn · Apr 8, 2019

1 minute ago, TriciaJ said:
No, because how do we know what she realized, when? She did initial a waiver to have an attorney present. When you're being interviewed by law enforcement about a patient death it's not out of the realm of possibilities that charges may come about. Many people on this site question if they should retain legal counsel on all manner of employment issues.

Gotcha

didnt know all the rules of posting. My bad

LilPeanut, MSN, RN, NP · Apr 8, 2019

Whew! I've gotten through the whole thread, all the articles and documents. Here come the quotes

On 4/5/2019 at 8:16 AM, ruby_jane said:
It is likely that in Texas she'd never practice with an unencumbered license again. Hindight being 20-20... I wonder if Vandy has a protocol to screen for impairment with a mistake of this magnitude.

I would really like to know this. I have not seen anything that says anything about whether she was tested for impairment when it happened.

On 4/5/2019 at 8:45 AM, JKL33 said:
That certainly is one thing that boggles the mind.
But, you know, when you have a NM that advises no need to document the actual medication administration and states that a magic machine will take care of it for you, all bets are clearly already off {not to mention the incident itself}

I can address this a little, knowing EPIC well. When you override a medication on the pyxis under a patient name, it automatically goes to the MAR so it can be signed off. When you scan the med, it will say "link to override pull of x med?" It's in a different color box (pink maybe?). Now, it doesn't record it as given, it just puts it in the MAR in preparation for being signed off. Epic was relatively recently new to the hospital, and my guess is the NM did not understand the difference between those two things. She knew that if you overrode something, it would automatically go to the MAR, but not that it wouldn't document as given (and I think the override pull eventually will drop off if you don't sign it). Everyone should have known that she should have signed off the med she gave, but the likelihood that it was in any way intentional is low, IMO

I'll go into conspiracy more later.

On 4/5/2019 at 8:48 AM, Dsmcrn said:
Leadership coverups from the very beginning

I've never been impressed with the "cover up". Think about how everyone feels after a horrific patient outcome. They are freaked out, if they like the nurse (remember, RV is white, young and pretty) and they'll all worried about malpractice and how they're going to get dragged into it.

So the nurse manager is dealing with it initially, is not great with Epic yet and mistakenly tells RV that she doesn't need to document the med given, because she thinks the fact it knows the med was pulled from the pyxis/accudose is enough. Mistake, not conspiracy

Then you have a resident (most likely) who was the one who called the ME, and then was hedging on what happened. S/he knew that everyone had been talking about it, but didn't know how far outside of the unit it was supposed to go, the whole thin white line. So he says "“maybe there was a medication error but that was just hearsay, and nothing has been documented in the medical record. There was no named drug in the notes.”" Now, at this point the ME should have asked more questions, or automatically sent the patient for autopsy. That was their failures, but not a conspiracy.

So the ME does the CoD and because he has not been told about any medications that were given. Without that information, he only has other clinical information to go on, and with that, it would seem her death was natural. She had a head injury, she stopped breathing, she died. That absolutely makes sense as an accident, except for the vec being given in there. If he wasn't told about the vec, how was he supposed to know? The mentioned that there was the patient safety notification that was sent out so he would have known from that, but I disagree, because that report was anonymized and he had no reason to thing it was his patient.

I don't know how the incident report didn't get turned in, but maybe someone was out on maternity leave or they sent out the sentinel event email and someone thought that meant they did the CMS report or something similar. There's not a good, logical, reason to cover this up. They reported it to the BoN, the left a huge paper trail, all of that points to a lack of incident report as being an oversight, not a intended action.

Overall, conspiracies and coverups are really hard to pull off, and I doubt they have the organization and cooperation to make a conspiracy this size.

On 4/5/2019 at 9:38 AM, Snatchedwig said:
It would probably be a great time to apply at that hospital. Probably a lot of vacancies now.
Related to the thread at hand: I'm so incredibly sad regarding this. Ranging from the loss of life, to a fellow nurse being charged, to the nurse at hand being so incredibly negligent with medication administration , to other nurses attacking her. This whole thing is incredible and setting a new precedent. Not entirely sure which , but a new precedent nonetheless.
I also think the public is watching how nurses react to this.

I think they are too, and I would personally be scared as a patient with the number of nurses who think RV's practices are ok.

On 4/5/2019 at 6:17 PM, CommunityRNBSN said:
This case is so upsetting. It sounds like she truly made several unimaginable errors. However, one thing that has been harped on in the news (because it is harped on in the report) is that she “ignored pop-up warnings” when she pulled the med. That assertion is clearly made by someone who is not a nurse. All of us have pop-up warning fatigue. I work outpatient and never even deal with dangerous drugs. And yet every time I log into a computer: “WARNING latex allergy” “WARNING you entered the wrong CPT code” WARNING med interaction WARNING the appointment you scheduled is at a time when the client is already scheduled WARNING WARNING WARNING. Everyone mindlessly clicks OK every time because otherwise you’d spend your entire day reading “bold-faced warning messages” (as the text of the article describes the event in question).

On 4/6/2019 at 7:50 AM, Dsmcrn said:
THANK YOU!!! There are way too many non-life threatening pop ups! Pop up fatigue is real!!!! Thank you

I am addressing these two together - these pop ups were appropriate, life threatening pop ups. And if there are not warnings, people will say "well, nothing warned me when I tried to take it out".

While alarm fatigue is absolutely possible, we are also able to overcome it and especially when overriding a medication is one where you should be paying attention to every error.

On 4/6/2019 at 9:54 AM, Jory said:
Think about it...they are not going to put a facility like Vanderbilt out of business. Their annual revenue is in the billions. CMS had to fluff a few feathers to appease the public, but they are not going to lose their ability to take Medicare and never were.

Not only that, people will lose their healthcare.

On 4/6/2019 at 10:34 AM, morelostthanfound said:
In my humble opinion, these accrediting bodies, (Joint Commission, CMS...) are a complete joke. These agencies' guiding missions are patient advocacy and safety but when do you recall them ever closing a hospital unit due to understaffing, dangerous nurse/patient ratios, or any processes such as this that allowed this error to cascade in the first place? Yeah, I've never heard of it either! What seems to be more on these auditors' radars instead are restraint order documentation and refrigerator temperature logs-seriously?

I definitely agree. It's hard, because I know all those rules are there for a reason, but it seems like there's way more focus on the stupid rules than on updated practices and equipment and staffing. I would rather they focus on quality of care first, then move down the line. And maybe some reality - how long can a fridge be out of range before a med is ruined or ineffective?

It just seems like we are focusing on little bitty stuff when there are still huge issues that need to be addressed.

On 4/6/2019 at 1:37 PM, Jory said:
I would have more respect for RV if she just admitted she made a catastrophic error by taking shortcuts and using herself as an example of what NOT to do. I honestly haven't read anything from her that demonstrates that she is more than "simply sorry" but I also can understand to some degree her attorney's have probably limited what she can say.
I am more ticked at the BON for taking no action on her. I honestly believe that someone at Vanderbilt--an institution that would without a doubt, have enough influence over the process, may have orchestrated (my opinion...I have zero evidence to back this up) her being cleared of any wrongdoing so that it would somehow reduce Vanderbilt's liability.

Doubt it. More likely it's the focus on "just culture" and it's not anyone's fault ever.

But I do agree, if I was in her position, I would have pled guilty and threw myself on the mercy of the court. I feel fairly confident they would be merciful in that case, but I would not be pleading no guilty, that's for sure.

On 4/6/2019 at 2:28 PM, TriciaJ said:
I still don't believe she was a safe nurse who experienced a cosmic convergence of everything bad happening in that one instance. I am so curious as to whether her immediate coworkers ever expressed any concerns. The fact that Vanderbilt had someone like this on the payroll, didn't report her to the BON, didn't report the sentinel event to CMS suggests a whole lot of sweeping under the rug.
We will probably never know the whole story.

Maybe this is just the bitter nerd in me, but I find popular girls can get away with anything and still sail through. I bet no one noticed because she's "so sweet".

18 hours ago, Wuzzie said:
And here is the TBI report which is even more damning. All of the posters who said the Accudose should have given a warning specifically about Vecuronium...well it did...multiple times. Also, I stand corrected because now RV is stating she looked at the MAR when she couldn’t find Versed in the patient’s profile. She did not, however, look at it prior to to attempting to pull the med. Also, she is now saying that she gave 1mg when first she said she didn’t know how much she gave and there are 2ml out of the syringe that supposedly contains the medication which would be 2mg. There are 8ml gone out of the other syringe. And finally she very clearly states that staffing was not an issue and never is in the unit she works.
https://ewscripps.brightspotcdn.com/3d/46/feb995d34e9782f9ae33e37391c0/0716-001.pdf

It is incredibly damning. And again I'll note, there are zero labels on the syringes, so it is always possible she mixed up which syringe was which.

Also, people keep saying TX BoN. It's Tennessee, not Texas!! ?

Wuzzie · Apr 8, 2019

13 hours ago, Dsmcrn said:
This interview with the TBI occurred before she realized she was going to be indicted and would need a lawyer.

I have to think if one messed up so badly that they killed a patient the first phone call a prudent person would make would be to an attorney.

NurseBlaq · Apr 8, 2019

6 hours ago, TriciaJ said:
No, because how do we know what she realized, when? She did initial a waiver to have an attorney present. When you're being interviewed by law enforcement about a patient death it's not out of the realm of possibilities that charges may come about. Many people on this site question if they should retain legal counsel on all manner of employment issues.

I asked the same thing in another thread and received no answer, only snark which is also what she did to you. You'll never get a straight answer but she speaks as though she's speaking for RV, hence why I keep asking if it's her.

Wuzzie · Apr 8, 2019

4 hours ago, LilPeanut said:
I am addressing these two together - these pop ups were appropriate, life threatening pop ups. And if there are not warnings, people will say "well, nothing warned me when I tried to take it out".

Funny you should say that because this was exactly the discussion early on. I just find it interesting that everything people have thrown out to deflect blame from the responsible party to the "system" has been blown out of the water.

Understaffed-nope per RV the unit is never understaffed.

Too tired because evil schedulers made her work too many days together-nope.

Too inexperienced-nope RV states she was comfortable with Versed.

Too inexperienced-nope, she is certified although in exactly what is unclear.

The Accudose should have had warnings-it did...multiple ones.

The Accudose had too many warnings.-RV states she was unfamiliar with Vecuronium so it's not like she's had to blow by the warning windows so many times they've become rote.

Seriously it sounds like people are just throwing excuses against the wall to see if any of them stick.

As far as Vandy's actions after the fact while sketchy at best they are not what killed the patient.

kp2016 · Apr 8, 2019

On 4/6/2019 at 7:22 PM, TriciaJ said:
Several of us have expressed doubts about ever having the confidence to practice again after such an event. I can't fathom going down the road and promptly getting a job in another ICU.

An ICU nurse who apparently doesn’t know the difference between Versed and Vecuronium, terrifying.

I honestly don’t know if the charges are fair or not but it’s very hard for me to understand why this nurse still has a license to practise nursing.

Jory, MSN, APRN, CNM · Apr 8, 2019

4 hours ago, LilPeanut said:
Doubt it. More likely it's the focus on "just culture" and it's not anyone's fault ever.
But I do agree, if I was in her position, I would have pled guilty and threw myself on the mercy of the court. I feel fairly confident they would be merciful in that case, but I would not be pleading no guilty, that's for sure.

No...bypassing MULTIPLE systems of safety has nothing to do with "just culture". It has to do with incompetent nursing and this is what the BON is designed do....discipline these nurses to protect the public.

If we do not have a line in nursing where this eventually becomes criminal...then we have lost who we are as a profession. A group of college graduates with a professional license should not have to be baby-sat.

It would if you feel she made an "error". RV didn't make an error. She was a sloppy nurse that has probably done similar things on the regular (I haven't bypassed that many systems of safety in my entire career) and it just flat out--caught up with her.

Jory, MSN, APRN, CNM · Apr 8, 2019

55 minutes ago, NurseBlaq said:
I asked the same thing in another thread and received no answer, only snark which is also what she did to you. You'll never get a straight answer but she speaks as though she's speaking for RV, hence why I keep asking if it's her.

Oh, there is no doubt in my mind that RV is reading what is online about her.