Nurse Charged With Homicide

MrMidazolam · Feb 11, 2019

I am a critical care nurse. The events that unfolded that led to a patient death are "never events." Tragedy of unnamed proportions. Therefore when they occur they are catastrophic events that arise when a system has failed. If there was no malice or negligence one must ask how did this occur. Versed is not a routine drug. Adverse patient events can occur even with this drug is administered especially when a patient is off in a remote area and is not being monitored. Never let an institution place you or your patient in an unsafe situation like Nurse Vaught and her patient was placed in. Advocate and speak up.

Daisy4RN · Feb 12, 2019

2 minutes ago, MrMidazolam said:
I am a critical care nurse. The events that unfolded that led to a patient death are "never events." Tragedy of unnamed proportions. Therefore when they occur they are catastrophic events that arise when a system has failed. If there was no malice or negligence one must ask how did this occur. Versed is not a routine drug. Adverse patient events can occur even with this drug is administered especially when a patient is off in a remote area and is not being monitored. Never let an institution place you or your patient in an unsafe situation like Nurse Vaught and her patient was placed in. Advocate and speak up.

Yes we should always advocate. But the questions remains why this nurse did not. Did she even know that the pt needed to be monitored. If she did know, then yes she definitely should have refused to leave the pt alone until safe or another RN present to monitor. If she did not know to monitor the pt, then how did she not know that esp working in ICU.

HomeBound · Feb 12, 2019

Night before last, I had a train wreck of a pt. Kidney transplant that had traveled, of all places, to Liberia and then to Costa Rica. Lovely places. Full of nice, humid, hot, delicious weather for bacteria and viruses to grow and mutate.

Hanta, corona, parainfluenza/influenza, RSV--ebola and even plague were in play.

Scared the living shite out of me. RSI, four teams of docs all yelling about whatever they wanted or thought, high intensity, high emotion, family crying, nurses asking me "HOW CAN I HELP??" Titrating propofol, insulin drip, mycophenolate drip, vancomycin drip, azythro drip, had nor-epi on hand to start if needed--massive infusions of RSI drugs---he's hallucinating and bucking, fighting the vent. restraints.

alarm bells and lights and people yelling. emotion. emotion. emotion.

The docs ordered his myco based on his history in the EHR. 500mg in 250mL with a D5 chaser.

What came? 1000 mg in same. Same bag. Same label. Same name. From a trusted source.

With everything that was going on, all of the yelling and alarms and intensity---I read the label of the drip prior to hanging it. It's JUST CellCept. It's just an immunosuppressant. It wouldn't kill him, just make him vomit maybe, if I dosed him wrong.

But I am suppressing his immune system. That makes him even MORE susceptible to infection, which is exactly what we were trying to fix---what is killing this guy?

If I had administered that CellCept the way it was sent, and not ordered---I could have enabled his system to shut down any immunity he may have had left to fight this infection.

I caught the mistake and I stopped what I was doing. I DELEGATED---to another nurse in a helper role---"Get Pharm on the phone. This is wrong. Please fix this now."

Reaction from Pharmacy? Exhasperation. Now they had to come and pick up the NIOSH med and replace it. Now it was a med error on their side.

Reaction from admin? Nothing.

Did I expect anything? No. Did I feel a sense of "I'm better than pharmacy"? No. It was my job. I am the last line of defense between my patient and all the bad things.

This is what bothers me about RV. It is her job to know. It is her job to protect patients even from herself.

Iheartwoundcare, MSN, APRN, NP · Feb 12, 2019

On 2/6/2019 at 8:06 AM, Wuzzie said:
This nurse did not make mistakes. She made a series of awful, inexcusable decisions including not doing the appropriate assessment of a patient receiving Versed. If she had, at minimum, done this the patient would not have died from the inadvertent administration of Vecuronium and we would be having an entirely different discussion.

Yes, I agree after reading the CMS report. My initial reaction was to support a poor fellow nurse that simply made a med error. This was definitely not the case....not by a long shot. It was sloppy and reckless nursing practice at BEST. The part that makes me cringe the most is hearing that she did not self report to the TBON and then Went. To. Work. Somewhere. Else.

Ummmm, huh? A patient died on your watch and you don't need some recovery time? Maybe a few months in the fetal position? Or is that just me?

I call BS.

TriciaJ, RN · Feb 12, 2019

9 minutes ago, Iheartwoundcare said:
Yes, I agree after reading the CMS report. My initial reaction was to support a poor fellow nurse that simply made a med error. This was definitely not the case....not by a long shot. It was sloppy and reckless nursing practice at BEST. The part that makes me cringe the most is hearing that she did not self report to the TBON and then Went. To. Work. Somewhere. Else.
Ummmm, huh? A patient died on your watch and you don't need some recovery time? Maybe a few months in the fetal position? Or is that just me?
I call BS.

No, it's not just you. Pretty sure I would hang it up and get a nice job selling shoes someplace.

JadedCPN, BSN, RN · Feb 12, 2019

37 minutes ago, Iheartwoundcare said:
Ummmm, huh? A patient died on your watch and you don't need some recovery time? Maybe a few months in the fetal position? Or is that just me?

Not just died on your watch, but undisputedly died 1000% as a result of your actions.

Yea, a few months in the fetal position balling my eyes out, in therapy, would be just the beginning.

JKL33 · Feb 12, 2019

3 hours ago, HomeBound said:
I caught the mistake and I stopped what I was doing. I DELEGATED---to another nurse in a helper role---"Get Pharm on the phone. This is wrong. Please fix this now."
Reaction from Pharmacy? Exhasperation. Now they had to come and pick up the NIOSH med and replace it. Now it was a med error on their side.
Reaction from admin? Nothing.
Did I expect anything? No. Did I feel a sense of "I'm better than pharmacy"? No. It was my job. I am the last line of defense between my patient and all the bad things.

You are to be commended, for sure - - but I thought you were going somewhere else with that story.

Sounds like the pharmacy has a huge problem. That was a near-miss as far as the system is concerned, but on their part individually it was a huge fail.

HomeBound · Feb 12, 2019

5 minutes ago, JKL33 said:
You are to be commended, for sure - - but I thought you were going somewhere else with that story.
Sounds like the pharmacy has a huge problem. That was a near-miss as far as the system is concerned, but on their part individually it was a huge fail.

Several points I was trying to make.

1. Delegation. It's your friend. If you feel overwhelmed, ask for help.

2. No matter the situation, alarms, yelling, stress, fighting patient, etc....there are people around you to help--use them. Distractions aren't an excuse and it's not easy for me to say, but if you keep on keepin' on when you feel that level of anxiety about a situation---you need to hand over control to someone else.

3. I never, ever said that there are no systemic problems here. Vanderbilt knew doggone well what they did, covering up this incident. They even tried to continue minimizing what RV did by trying to say she "had no time at all to document the drug given". She left the Rad dept and did other menial tasks (in her own words) for 45 minutes. She didn't have time? When she entered the doc box after she learned it was Vec...she said "It's my fault. I did this" and NP walked out but said before she left, "I'm so sorry" to her. She didn't feel it necessary to sit her butt down and document this?

Risk Management got hold of her and coached her. I've seen this before. They swoop in and scrub the incident---the best they can. Then they tell you not to talk to ANYBODY or write anything down. I went thru this with a sexual assault on hospital grounds and a co worker.

Pharmacy is a problem sometimes. I've worked places where we waited for some attitude plagued pharmacist to verify a drug in an urgent or emergent situation---and it endangered lives. Egos are not exclusive to doctors.

Vandy, according to the report, saw that the only education that needed to be done was....

1. transport to radiology policy needs to be clarified to make sure there is a nurse with the patient ...nothing about monitoring, just a body is there.

2. a "yearly competency" be in place to cover sedation.

Those are already in place in 99.9% of hospitals as yearly comps. They wanted to avoid a systemic knowledge and possible spread of the information, thereby losing control of the narrative. So much for concern for patient safety.

RV brought the vial down to PET. She reconstituted it THERE. This makes me just nauseated---she had every chance inside the confines of the ICU to identify her error---red boxes pop up on the acudose...she blew thru that. she clearly only knew the brand name of midazolam...blew past that to "anything that looked like it's right". She read the directions for reconstitution....looked at the vial....claims "she doesn't remember reading the name"....blew thru that safety check. She puts it in a baggie and writes on it---Versed 1-2mg PET....looks at the baggie when she's got the vial in it...doesn't see any type of weirdness with the big red cap and danger paralytic label....blew thru that.

The drug was ordered and verified for 10 minutes and had populated in the acudose. She didn't know what the proper name for versed is---midazolam. Instead of ASKING FOR HELP, she blew thru that.

She reconstitutes it, taking her time.....down in PET. Blew thru that safety check, to even look at the label. Maybe....oh....teach her preceptee what VERSED does for patients in radiology? Blew thru that opportunity to stop herself.

And all Pharmacy and Vandy at large can offer is a yearly competency that most people click as fast as they can thru and take the test 400 times until they pass it?

Yeah.

My story is a perfect storm of all of the excuses being offered here in RV's defense. Rushed. Alarms. Multiple tasks. Urgent situation (which in RVs case, it was NOT). Multiple orders. Fast pace. I am overworked. I was on 4th night in a row. Tired. Bleary eyed.

But I had people around me who check and double check me if I need it. If I falter, someone is right there to pull me back. Vanderbilt does not do this for their nurses, CLEARLY.

I never, ever said that Vanderbilt holds no responsibility. I actually know another story about them, involving a doctor and a tech and a death. I won't step foot in that hospital. Ever. And that was.....1996? They haven't changed an iota. The arrogance and disdain that Vandy displays is astonishing. I don't care if they polish up their PR by vaccinating puppies at the shelter and doing homeless blanket drives....the problems there are systemic and institutionalized---I've seen several such "magnet" status facilities, teaching hospitals---particularly in the South---display this type of "it's our way or the highway" and if you don't like it? We'll ruin you.

RV is part of that systemic problem--first off because she was taught better in school, and while working, she decided somewhere along the way that those rule thingies are just for nursing students. That's arrogance. Nobody pulled her up hard and in her mind, if nobody pulls you up hard, you probably aren't doing anything wrong. No critical thinking or introspection on her practice as a nurse. Vandy let her get away with it, because it's expedient.

Jory, MSN, APRN, CNM · Feb 12, 2019

On 2/5/2019 at 8:49 PM, mtnNurse. said:
Would this happen to a doctor if a fatal mistake was made?

If he willfully bypassed every red flag? Yes, he would. That is why Michael Jackson's physician is sitting in prison.

Jory, MSN, APRN, CNM · Feb 12, 2019

18 hours ago, mtnNurse. said:
I do think I'm more prone to want to give her the benefit of the doubt (again, not in excusing what she "should have" done as a nurse but excusing that what she did do is not criminal behavior) than some of you awesome superstar critical care nurses who have decades of experience under your belts, because it's more recent in my mind how overwhelming the first couple years of work are. Maybe she didn't have enough experience to be in the resource role she was in. Maybe she was striving so hard to be a "good worker" and didn't know yet how to prioritize better and how to stand up to pressures to work faster. Can any of you try harder to imagine what that day was like for her, and so imagine that perhaps consequences such as loss of licensure is warranted, but years in prison and life-time label as felon for this is cruel and unusual punishment?

1. It is criminal behavior because it meets the legal criteria. You seem to be on this bandwagon that intent had something to do with it. It doesn't. She didn't intend to kill the patient, but she intentionally bypassed MORE THAN ONE checkpoint that caused that patient's death.

2. She had a certification for the area where she was working. We hold certifications in high regard in our profession. She can't claim ignorance after she passes those kinds of tests. She's had also been a nurse for about 3 1/2 years. Not a new grad.

3. There is ZERO evidence in the CMS report that she was overwhelmed or rushed. This is an assumption made by many with no evidence to support it. She simply didn't want to wait for the medication to be verified by pharmacy. She didn't have the chart in front of her...patient could have easily had an allergy to versed or an equally fatal drug interaction. She was not in an emergency situation.

4. You are also assuming, again, she is going to spend "years in prison". It has a 2-5 year POTENTIAL sentence and the judge absolutely has the leeway to suspend 100% of it if he/she wants to. My guess is she won't spend one day there or if it is, a very short period of time.

You are still not answering a very obvious question: How much negligence are we going to be OK with in our profession? How much complete disregard for practice standards will we tolerate?

As a profession, if she gets a pass then we know one thing for sure: We, as a profession, are willing to tolerate any level of negligence no matter how it damages the patient.

Wrong blood? No problem

Don't want to wash your hands? Don't worry, go ahead and clean up that c-diff patient and then run into the next room with your immunocompromised patient. I'm sure they'll be fine.

Wrong breast milk? No problem, they used to have wet nurses didn't they? Parents will never know. Breast milk comes from a mother that was positive for many illegal drugs on admission and an IV drug user, but hey...it's only milk right?

Seriously...there will be no end.

Horseshoe, BSN, RN · Feb 12, 2019

If any of you follow ZDoggMD's Youtube channel, you may have seen his video on the Vanderbilt medication error. Like most of us, he was shocked and appalled.

After watching this, I saw he posted his reaction to the criminal charges. I was a little surprised at his passion, based on his original video.

His take will upset a lot of nurses here on AN.

One good thing about seeing these videos is that it reminded me of him and his channel. I binged watched a bunch of his videos and found a lot of them to be quite thought provoking.

Advanced Practice Columnist / Guide · Feb 12, 2019

11 hours ago, TriciaJ said:
No, it's not just you. Pretty sure I would hang it up and get a nice job selling shoes someplace.

I wouldn’t even consider driving for Lyft for fear I’d miss a child crossing the street.

Nurse Charged With Homicide

Should Radonda Vaught, the nurse who gave a lethal dose of Vecuronium to patient at Vanderbilt University Medical Center, be charged with reckless homicide?