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.

[Horseshoe, BSN, RN]

16 minutes ago, Crow31 said:

To answer the question the article originally was asking, I would suggest maybe a specific override code for paralytic medications. In hopes this may decrease the human error chance a bit because we all know that alarm fatigue is a real thing. (where my Critical Care nurses at?) Stuff pops up all the time even when we chart and get certain medications. My suggestion is just that a suggestion. Here's how the code would work. 1. Pick the paralytic you want. 2. Now a hard stop pops up something like "Paralytic code required" 3. Enter Code Maybe not a practical idea using a code, but the concept still remains. There needs to be a hard stop with certain medications. I mean crap I have a hard stop to put in a pain scale when I give Tylenol.

Yeah, I mentioned earlier that in some of the comments to one of ZDOggMD's videos that someone talked about their facility having such a pop up. It says something like "Is this patient ventilated or about to be intubated?" If you answer no, the medication will not be dispensed. I thought that was a pretty good solution, though if you have someone who deliberately wants to kill a patient (and there have been nurses who want to hurt patients so they can come in and "rescue them, " and others have wanted to outright kill patients for other reasons), there may be no 100% foolproof solutions.

[Crow31]

50 minutes ago, Wuzzie said:

No they aren't. Her cavalier approach to medication administration is what's insulting. She didn't make one lapse in judgment. She literally messed up every single step of the way. When we are in nursing school we are taught that we need to be careful when administering medications because the wrong medication, route, timing and/or dose can harm a patient. This is a basic nursing principle that every single one of us comes out of school understanding. You don't just "forget" those kind of things. She was reckless in her practice and another human being was harmed. She needs to stand before a judge and explain herself. I understand your position and your apprehension, I really do, but we have to set a limit somewhere. I think this is the limit. We aren't above the law. This should be a wake up call to all of us that we need to scrutinize our practice and always, always do things the right way.

We'll just have to agree to disagree on this one. In a way all med errors are "reckless" not just the ones that end in death. Trust me, this is a huge wake up call for me. I no longer work in an area that this magnitude of a med error could occur. I have no access to paralytics, but I have worked in areas where I could see this happen again to someone else especially in the ER. Probably already has and that's why we have pop ups of look like/sound a like drugs and why the vials usually have paralytic written on them. I know we all work hard and would hate to see someone go to prison based on criminal charges for their malpractice mistake.

[Crow31]

9 minutes ago, Horseshoe said:

though if you have someone who deliberately wants to kill a patient (and there have been nurses who want to hurt patients so they can come in and "rescue them, " and others have wanted to outright kill patients for other reasons), there may be no 100% foolproof solutions.

Woah, wait! I was trying to prevent unintentional med errors. If someone wants a medication like a paralytic with the intent of harm well there isn't a whole lot you can do especially if they work in a unit that has access. By the way that person should definitely be charged with the charges this woman has been and worse.

[Corey Narry, MSN, RN, NP]

51 minutes ago, Crow31 said:

Thank you for sharing. This is a bit more helpful. I guess to know this kind of case isn't the first time kind of puts my decision into perspective. I've worked in all kinds of areas. Including an ER where medications were not scanned. Right now I work at a place were something of this magnitude couldn't happen, but I would rather not work here for the rest of my life. I'll be transitioning out of nursing. Thanks again for your response.

I worked in a busy inner city ER too before bar code scanning started and we only had access to meds from the Pyxis if they were High Alert medications or controlled drugs, otherwise meds are in an open cabinet in the locked Pharmacy which nurses had in and out access to. Looking back, that is quite a scary situation but I honestly never had a med error there. I could attribute that to the fact because there were very little safeguards, I am prompted to check my 5 rights more vigilantly.

[Crow31]

3 minutes ago, juan de la cruz said:

I worked in a busy inner city ER too before bar code scanning started and we only had access to meds from the Pyxis if they were High Alert medications or controlled drugs, otherwise meds are in an open cabinet in the locked Pharmacy which nurses had in and out access to. Looking back, that is quite a scary situation but I honestly never had a med error there. I could attribute that to the fact because there were very little safeguards, I am prompted to check my 5 rights more vigilantly.

That's awesome and hard work too. I wonder if you aren't on something there about a possible downside of all the technology. Maybe it takes some of the thinking out of medication administration? Especially when you are trying to cut corners when you're busy. I mean you could just scan and go(disregarding pop ups because those happen all the time) which is convenient, but maybe too much? Hmm... I'll have to think about that.

[Corey Narry, MSN, RN, NP]

4 minutes ago, Crow31 said:

That's awesome and hard work too. I wonder if you aren't on something there about a possible downside of all the technology. Maybe it takes some of the thinking out of medication administration? Especially when you are trying to cut corners when you're busy. I mean you could just scan and go(disregarding pop ups because those happen all the time) which is convenient, but maybe too much? Hmm... I'll have to think about that.

Hence, my other thoughts on inattentional blindness:

https://www.ismp.org/resources/inattentional-blindness-what-captures-your-attention

Also interesting:

https://www.ismp.org/resources/safety-enhancements-every-hospital-must-consider-wake-another-tragic-neuromuscular

[Horseshoe, BSN, RN]

14 minutes ago, Crow31 said:

Woah, wait! I was trying to prevent unintentional med errors. If someone wants a medication like a paralytic with the intent of harm well there isn't a whole lot you can do especially if they work in a unit that has access. By the way that person should definitely be charged with the charges this woman has been and worse.

Yeah, I get that. I agree with you. I'm just saying that no matter how hard we try, there's no way to prevent all bad outcomes, particularly if the nurse has nefarious intentions. But we still need to try.

[Wuzzie]

3 minutes ago, Crow31 said:

That's awesome and hard work too. I wonder if you aren't on something there about a possible downside of all the technology. Maybe it takes some of the thinking out of medication administration? Especially when you are trying to cut corners when you're busy. I mean you could just scan and go(disregarding pop ups because those happen all the time) which is convenient, but maybe too much? Hmm... I'll have to think about that.

I kind of look at all of our technology as a double-edged sword really. I think we rely on it a little too much sometimes a lot too much. Prior to medication dispensing technology we HAD to be vigilant because we had no back-up.

[Crow31]

6 minutes ago, juan de la cruz said:

Hence, my other thoughts on inattentional blindness:

https://www.ismp.org/resources/inattentional-blindness-what-captures-your-attention

Thanks again for sharing. I wonder if anyone will bring inattentional-blindness into the courtroom. Super scary even for those who are being careful. I see more why certain medications need that second nurse and maybe my suggestion of a hard stop? ?

[Crow31]

8 minutes ago, Wuzzie said:

I kind of look at all of our technology as a double-edged sword really. I think we rely on it a little too much sometimes a lot too much. Prior to medication dispensing technology we HAD to be vigilant because we had no back-up.

9 minutes ago, Wuzzie said:

I kind of look at all of our technology as a double-edged sword really. I think we rely on it a little too much sometimes a lot too much. Prior to medication dispensing technology we HAD to be vigilant because we had no back-up.

Look at the article Juan de la cruz replied to me about med errors of inattentional-blindness. If that's a thing, then crud. The only thing I can think of is that certain medications for sure need hard stops and a second RN.

[klua]

It's been interesting reading everyone's point of view. There are very passionate arguments on both sides! For me, what it boils down to is pattern. If I was on her jury, I would want to know what has she been like as a nurse for these years. There was a nurse at a place I worked at who accidentally gave someone 100 units of insulin. She was drawing up heparin at the same time as insulin. The patient ended up ok and the RN was horrified of the mistake she had made.

There was another nurse at this place I worked with who gave someone a different benzo. Lorazepam instead of Alprazolam. The patient had both meds. The nurse just pulled the wrong one. The patient was fine. The nurse basically just brushed the mistake under a rug.

Nobody died, the patients were fine, but what was different about these two for me was the nurse. The RN who gave the insulin had a few years of experience and had shown she was a normally excellent nurse. She just made a terrible mistake. The RN who gave the wrong benzo was different. She was a nurse who made mistakes in all aspects of nursing. I won't go into details, but she was just a generally bad nurse.

If these situations had ended up very badly and the nurses were charged by the D.A., their histories would matter to me. There are good nurses who sometimes make bad mistakes. There are also bad nurses who make bad mistakes.

This nurse who gave Verconium instead of Versed made numerous errors. I don't think anyone is debating that. But what has she been like as a nurse? A good one who made a bad mistake, or a bad nurse whose mistake ended in a death? That makes a huge difference. Whether or not she should be charged is really for me not a debate anymore. She has been charged. I assume especially with all the publicity it will be going to trial. She has admitted to it. What matters is what comes out in court and what the ultimate penalty will be.

Do I think she should go to jail? No, but there has to be some accountability depending on what her history has been like. If she is a good nurse who made a terrible mistake, I would hope it would eventually just end in a probation, supervision at work, or training. I'm not sure how that works. But if she has a history of being a generally bad nurse, losing a license might be in the best interest of all future patients she could have.

Btw, I have been a long time lurker on this site. I haven't really posted, but I love this site! I'm learned so much from all you nurses?

[Wuzzie]

12 hours ago, klua said:

Do I think she should go to jail? No, but there has to be some accountability depending on what her history has been like. If she is a good nurse who made a terrible mistake, I would hope it would eventually just end in a probation, supervision at work, or training. I'm not sure how that works. But if she has a history of being a generally bad nurse, losing a license might be in the best interest of all future patients she could have.

But she didn't make just one.