Nurse Charged With Homicide

[Nurse Beth]

Radonda Vaught, a 35 year old nurse who worked at the University of Vanderbilt University Medical Center, has been indicted on charges of reckless homicide. Read Nurse Gives Lethal Dose of Vecuronium

Radonda is the nurse who mistakenly gave Vecuronium (a paralytic) to a patient instead of Versed. The patient died.

[princessandraya]

Here is my problem… She overroad safety checks that were in place to prevent errors like this from happening. If she wasn’t familiar with the drug she should’ve asked. We are taught that in nursing school. Whether she was a new nurse or not she didn’t follow the 5 rights, therefore, she deserves to be punished because if she had followed the 5 rights this would’ve been preventable !

[TNPedsRN13, BSN]

I have long lurked on allnurses, but this topic keeps popping up all over Facebook and here, and I just felt the need to break out of my lurking dispel some misconceptions. ?

First, I'm not sure how I feel about her being charged. However, there were multiple safeguards in place that she just flat out ignored. I have heard many speak out about the institution and how they are to blame with terrible staffing. She was a help-all nurse. Also known as a resource nurse or a float. These positions have requirements for extensive training and a minimum amount of experience.

As a help-all, she would have had exactly zero patients assigned to her care. They are often floated to floors that have very sick patients or have a large influx of patients at one time. The patient that she escorted to imaging would have been her only one.

I think it is always pertinent to look at the system and see what we can do to prevent future errors. However, in this case, I do not believe it would have made a difference as she bypassed and ignored all policies to begin with.

[yournurse]

12 hours ago, hyllisR said:

Also, Versed is a procedural drug. Why in the world did the doctor order Versed instead of Ativan or Haldol? It sounds like there was plenty of standard protocol deviations going on.

Probably a new resident. Not sure why. It's a bit of an overkill, versed for an older lady? Hm. That's interesting. I would like to know more about the doctor who ordered the versed and the other factors surrounding this incident. So many things that could have affected her way of thinking that day. On my unit, you can't be a resource unless you've been on the unit for a few years.

It's also very important to not rush things when it comes to nursing. It's like when I used to have road rage. I don't anymore. Anyway, a driver passed me on the freeway. I later passed the guy and he got into an accident! That could've been me!!! What if I rushed into and out of traffic that day? I was angry that he passed me. Why can't we just wait a minute for the pharmacy to verify a drug to get through another safety check? You know? So simple. A minute to save a life.

Anyway, moral of the story. Be in the moment when you're dealing with patients especially when giving meds. You are where you're supposed to be, giving drugs or waiting in traffic. Keep that in mind. What if you meet your Prince Charming while in traffic? you never know!!

I forgot to answer the question. One life is already damaged, why damage another one?

[Wuzzie]

9 hours ago, NurseJenRN1975 said:

Second, the doctor should have put in the order himself. (Or herself—whichever is appropriate).

However, the physician is not innocent in all of this. His or her failure to enter the order into the system in a timely manner could have prevented this entire scenario. Had the med popped up in the patients MAR, an override would not have been necessary.

Another safety feature that would have helped prevent this tragedy would have been to require another RN to validate the action of pulling and administering a paralytic drug, especially one not currently listed on the patient’s MAR, requiring an override on the part of the nurse. Paralytics are dangerous drugs that should be treated with respect and double-checked for the safety of the patient. I mean, good Lord, we do that with regular insulin and blood products—why not PARALYTICS???

I don't recall anywhere there being mention of this order being a verbal order. The medication was ordered, verified by the pharmacy and available in the Pyxis a full 10 minutes prior to her attempt to remove it. They pulled the time log. I have no idea why she couldn't find it although I have my suspicions.

Requiring a second nurse to validate and pull a medication used in emergencies is not reasonable. Can you imagine trying to hunt somebody down to do this when time is of the essence?

[Crow31]

8 hours ago, rural-rn-15 said:

If you read the report of the investigation (which was available online when this was in the news a while ago):

1) she admits she did not even look at the name of the medication on the vial. Zero checks. Zero. For what would have been a high-risk medication even if it was Versed.

2) She overrode the Pyxis and selected "the first drug that started with a V" from the list.

3) She administered the drug and then left right away. Again, even if the drug was Versed, you do not leave a patient alone and unmonitored after a dose. Patients sedated with IV Versed should have Q5 vitals and sedation checks.

This isn't just an oops that could happen to anyone and it just happened to have dire consequences this time. This is a failure to act as a prudent nurse. No matter what department you work in, no matter where you're floated, no matter what the medication even, it's our bound duty to double- and triple-check the med against an order. It's our duty to know the med we are giving and its side effects. I know it's terrifying and I know we are all seeing ourselves in her shoes but in my opinion, this is not an "all nurses are human" type of error. It's criminal negligence.

Even you say negligence not reckless homicide. I think that is what shocks most people. That a med error which leads to death and this could be you.

[AuntPegRN]

Everyone in every job makes mistakes. There is such a lack of forgiveness and compassion when the mistake is made in the nursing profession. There was no intent of harm and personally I think she should not be charged or lose her nursing license.

[Crow31]

On ‎2‎/‎5‎/‎2019 at 8:16 PM, FolksBtrippin said:

If I had known that this was possible, I would not have become a nurse.

In nursing school we went over a case, where the nurse gave a med by the wrong route, which ended up in the patient's death. Not only did she not get falsely charged with murder, but she kept her license, she kept her job, and became a champion of prevention in the hospital.

Me neither. I'm seriously looking into another career starting today. Maybe rash and over dramatic for some, but not illogical to me. Really think about your day and the factors that play against you to make mistakes and then think if it's possible to make a lethal one? The answer of course is yes and the higher the chance depending on where you work. To think of how something like this would effect my family. I'm out!

[Horseshoe, BSN, RN]

I agree with many others who feel this nurse didn't just "make a mistake." She made a series of egregious actions and should suffer serious consequences. I think where the divide lies between many of us is whether the serious consequences should be professional and civil penalties (the "lose her license and face a civil lawsuit POV") or the "lock her up" mentality of applying criminal penalties.

A very few sample here don't think she should even lose her license. For that point of view, I'd like to hear a better reason than "it's her livelihood!'

[beachynurse, ASN, BSN]

How horriffic for both the nurse, and the patient's family. While I am horrified at the medication error, that's what it was. A tragic medication error that should have been utilized as a training tool to prevent something like that from ever happening again. The hospital needed to look at it's procedures and put new ones in place. As far as her license, I am sure that the guilt that she feels is more punishment than losing her license could ever be. I think that would be way too harsh. Possibly be mandated to take some medication training, monitored for a time and then returned to full duty. I think that is a much fairer outcome. We as nurses can be so cruel to each other, and I understand that this error cost a life, it was just that, an error. And by no means am I minimizing the error, I totally understand it's cost. We see physicians make deadly and costly errors and they go back to practice as though nothing happened, but nurses are crucified. Lets stop that kind of behavior, please!!!!!

[mbarthold]

What happened to "Errors are SYSTEM process errors"?

And the 'no-blame' culture? Don't be afraid to report a mistaken. We're not interested in punishing you - we want to help fix the problem so it doesn't happen again.

It seems to be missing, somehow.

[PhyllisMSN, MSN, RN]

19 hours ago, juan de la cruz said:

It’s not far off to order Versed. It’s shorter acting than Ativan. Atypical antipsychotics like Haldol would be a bizarre choice for a patient who is totally alert, oriented, and only complaining of being nervous inside enclosed spaces.

In my facility, Versed is only given to monitored patients.

[PhyllisMSN, MSN, RN]

I think she should be reprimanded, but not lose her license. According to CMS, there are 100,000 deaths due to medical errors each year. Are all of these doctors losing their license?

I promise you, whenever an incident like this happens, it is never one person at fault. It is a system process error. I am just not ready to put all of the blame on this nurse. For example, how is a paralytic readily "available"? What pharmacy does that? In my facility because a paralytic is only used to intubate, or when a patient is intubated, paralytics are only available in critical care areas and they are in a "kit" for intubation drugs. We just do not have all of the information available to us. I fear we are only hearing about this because she is a nurse.