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.

[JKL33]

18 minutes ago, juan de la cruz said:

Would she override that too? that is certainly possible but we also have to reassure the public that systems such as bar code scanning exist for their protection. I spoke to a layman friend about this case and his reaction was "now I'm afraid to be a patient in a hospital".

Ha - I just erased a diatribe about how often we are instructed to override inappropriate error messages (depending upon how carefully or shoddily everything is programmed and how the ordering system is used overall)...I said I've had more than one professional-but-somewhat-terse conversations with important people trying to inform them how it is not appropriate to instruct nurses to override error messages because you don't yet have the system working the way you want it to....

Guess what happens when there are just too many inappropriate errors or hard stops that you have to override? Override becomes "NBD" almost instantly.

Re: Reassuring the public...

Do you feel things are generally safe in hospitals? Sincere question, of course. ?

[Corey Narry, MSN, RN, NP]

19 minutes ago, JKL33 said:

Do you feel things are generally safe in hospitals? Sincere question, of course. ?

I feel I work in an ICU that strives for safety at all times.

Our nurses are not allowed to override meds in non-emergent situations and actually get written up by Pharmacy for doing so. Pharmacy is just a phone call away so if they want a med order approved quicker, all they need to do is call the ICU Pharmacist and the nurses carry phones so calling is easy.

Our Pyxis has a blue line in a rectangular area where nurses would stand to get meds. That's a reminder for anyone, provider or any other hospital staff that the area is a no interruption zone because nurses need to focus on the act of pulling the right medication alone.

Like I mentioned already, we have bar code scanning in all the departments and we have been using Epic since 2013.

We have break nurses as well. We use a similar Resource Nurse system but these are seasoned ICU nurses who won't take BS from anybody (physician or otherwise) and won't be cajoled into doing menial work because another nurse is too lazy to do it.

Have errors happened? I'm sure but hopefully not this magnitude.

[Susie2310]

4 hours ago, Dsmcrn said:

This is a horrible direction for our profession.

Medical errors have been shown to harm or kill large numbers of patients annually. Many medical errors go unreported. Medical errors are not currently reported on patients' death certificates. I read someone contrast this to the aviation industry, where near misses/accidents whether or not they result in passenger deaths/injuries are closely investigated and action taken.

I don't believe this is a horrible direction for our profession; I hope it is a wake up call that will lead to changes that will result in improved patient safety. Yes, criminal charges can be brought against licensed health care professionals. Some nurses seem shocked at this. Our licensure means that we are held legally and professionally responsible and accountable for meeting professional standards of care. The purpose of our license is to protect the public. Maybe more people who are either considering or are in the process of becoming licensed health care professionals will give serious consideration to the implications of professional licensure.

My hope is that the general public will get more involved politically in advocating for patient safety. Health care as an industry relies on the confidence of the public. I believe that the general public has lost much trust in the health care industry.

[Pippynurseuk]

The bit that I just cannot get my head around is that the nurse didn't actually read the label on the vial. I simply cannot imagine ever sticking a needle into a vial and drawing up medication without actually looking at and reading the label.

I can certainly see some aspects of the Swiss cheese effect, perhaps she was rushed and overworked, perhaps she was in a role which was not appropriate for her experience, perhaps her orientee was a distraction, perhaps there was a lack of communication and some confusion and she believed somebody else would be monitoring the patient, maybe someone was having a hissy fit over the holdup getting the patient scanned, maybe she was having a spectacularly bad day. .........It takes seconds to read the label on the vial.......

I'm from the UK and I work in patients homes not in a hospital so completely different culture. I am curious how technology; automated medication machines, scanning etc has affected nurses thinking and behaviour. What are people's honest opinions, has this created a culture where it's the norm to not read labels on vials? Not judging, just curious.

[Workitinurfava, BSN, RN]

Maybe the nurse was chemically impaired or dealing with some mental issues, we will never know because apparently it isn't important to check when charging someone with homicide. We are assuming she wasn't. If she was high on something, things make more sense, if suffering from a mental condition, then its another story. The case has holes.

[Wuzzie]

2 hours ago, Workitinurfava said:

How do we know that the hospital didn't set some of these things up?, like planting the syringes, they definitely aren't on her side and probably want to hurry up and just be done with the whole case. The hospital didn't allow for any mental evaluations to be done on the nurse, yet concluded all of these things. Maybe something was going on with her mental state at the time.

OMG! Now you’re really reaching. The hospital PLANTED the syringes? Did you read the CMS report? Wait, you couldn’t have read it and come up with this idea. If you do read it you’ll see that what happened is in the nurse’s very own words!!! And where do you get that the hospital refused a mental evaluation? The conclusions the CMS, not the hospital, came up with were based on direct deposition of each of the staff members involved.

[Wuzzie]

35 minutes ago, Workitinurfava said:

Maybe the nurse was chemically impaired or dealing with some mental issues, we will never know because apparently it isn't important to check when charging someone with homicide. We are assuming she wasn't. If she was high on something, things make more sense, if suffering from a mental condition, then its another story. The case has holes.

The case has zero holes.

[Wuzzie]

1 hour ago, JKL33 said:

However, although it would have been another precaution, I don't encourage anyone to use BCMS as a primary tool. It's a second or third check, aka "confirmation" at best. I see plenty of people who grab stuff out of machine and don't look carefully at it - because they plan to scan. Although they are a great tool, the ways in which they have been promoted is unfortunate. There just is no substitute for the 5Rs and I think we should spend some energy on promoting that, low-tech and uncool as it may be.

I am embarrassed for our profession that we have had to resort to this kind of technology to make up for the fact that we are not doing our jobs the way we were taught. The bar code scanning is in place because we take short cuts and don’t do the 5 rights like we are supposed to. We wouldn’t need it if we were.

[TriciaJ, RN]

14 hours ago, johsonmichelle said:

Of course not. I don't think you understand my point. Apparently this nurse was serving as a resource nurse. For example, if you are a medical surgical nurse, and you were pulled to the ICU as a resource nurse/helping hands and a physician ordered an ICU medication that was appropriate but you never received training for it, would you administer the medication?

1. Ask the charge nurse: is there anything specific I need to know about Versed? 2. Do a quickie look-up on whatever resource I have on hand 3. LOOK at the med I've pulled and make damn sure it's what was ordered 4. Call the ED and say I'm running late on the swallow study; I need to stay and monitor a patient.

This was not an error. This was a nurse demonstrating no more care and attention than you could legally expect from a layperson. Yes, the hospital bears culpability for a lot of things. But as nurses we are held to a certain standard of practice and responsible for our own actions.

[johsonmichelle]

4 minutes ago, TriciaJ said:

1. Ask the charge nurse: is there anything specific I need to know about Versed? 2. Do a quickie look-up on whatever resource I have on hand 3. LOOK at the med I've pulled and make damn sure it's what was ordered 4. Call the ED and say I'm running late on the swallow study; I need to stay and monitor a patient.

This was not an error. This was a nurse demonstrating no more care and attention than you could legally expect from a layperson. Yes, the hospital bears culpability for a lot of things. But as nurses we are held to a certain standard of practice and responsible for our own actions.

You did not answer my question, I'm not trying to deter from the original case, because the nurse in question is an ICU nurse. I'm not an ICU nurse, therefore I would not administer ICU medications under normal circumstances especially in this case. It's also part of the unit policy not administer those type on my floor unless it was an emergent situation.

[TriciaJ, RN]

14 hours ago, johsonmichelle said:

The link was posted in one of the earlier posts. Page 1 or 2, I think. (Correction: page 14. Didn't realize it was that far in.) It certainly did blow my mind. No, it wasn't a tragic error caused by stress and poor staffing (although they could certainly be factors). This was caused by an incredible degree of sloppy, inattentive nursing practice.

I feel bad for newer nurses who think they need to get out before it happens to them. Yes, errors certainly happen and for a lot of reasons. But this wasn't one of them.

[mtmkjr, BSN]

1 hour ago, juan de la cruz said:

I think bar code scanning could have saved the patient's life and snapped this nurse's brain back to the realization that she had the wrong medication in her hands. It's no excuse for her actions but we now know these mistakes can happen so why not ensure that extra layer of protection at all times. Would she override that too? that is certainly possible but we also have to reassure the public that systems such as bar code scanning exist for their protection. I spoke to a layman friend about this case and his reaction was "now I'm afraid to be a patient in a hospital".

Just last week I was giving insulin to a patient who had been taken to another area. I had my WOW with me.

I had pulled the correct dose from the pyxis, checked the vial, expiration date and applied the label - did everything correctly, but when I got to the patient my mind simply bypassed the scanning process and I administered the insulin. I was horrified with myself, but fortunately everything had been verified and the patient got the correct med. I think what happened was that I struck up a conversation with the patient and some other people who were attending him - a momentary distraction.

Now move on to the actions of this nurse who did none of the checking and then proceeded to another area while in conversation with her orientee about who-knows-what (obviously not about correct processes and procedures...). She at this point believes that the Versed has not yet been verified, and in her rush to complete the task I I think it is more likely she would have also bypassed scanning. In her mind it would not scan if not in the patient's profile.