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.

[LilPeanut, MSN, RN, NP]

1 minute ago, juan de la cruz said:

I believe she was terminated after maybe a few days. I still don’t know how she found employment right away unless her references didn’t mention the case.

If they were trying to keep this quiet, they likely kept their mouths shut.

[JKL33]

1 minute ago, LilPeanut said:

Why would they mention it as a factor with her having dismissed it then, if it actually was a stat order?

I don't know what to say. The whole quote regarding this is an ambiguous sentence or two from someone who may or may not ever touch patients or these machines, whose team performed an analysis.

Okay. I'll just quote the report (quote is from the MAPST, Manager of Adult Patient Safety Team, p.22):

Quote

12/26/17 - 2:59 PM: Vecuronium override in Acudose. VE was entered in the Acudose and the machine defaults to generic medications - Vecuronium popped up. Versed [brand name] did not show on the screen. A warning in red box was visible for an override stating that is [sic] should be for STAT orders.

My point is that we do not know the status under which the medication was ordered (STAT, NOW, Routine, PRN, etc). I have not been able to find that. She may have had reason to believe that it was entered as a STAT order since the patient was already down in radiology waiting for the med. But what we can't assume is that it wasn't entered STAT just because the situation was not in fact a dire emergency. It may indeed have been ordered STAT. She may have had reason to know that in such situations where the med is wanted sooner rather than later, it would be entered as STAT.

You see what I mean? So the wrong med pops up, somewhere on the screen is the override button, which has a warning saying it is for STAT orders. Given the perversion of the use of STAT/NOW order status, she very well may have believed that it was a STAT order.

Or she may have overlooked the 'red box' (whatever it was) like she overlooked everything else. ?

The thing is, aside from RV, if you (we all) are interested in keeping patients safe, it does matter how override is commonly used, off the record, in that facility. Not how I use it or how some other nurse uses it, but what the tenor of its use is in that facility. This could be a situation that was utterly out of the ordinary with regard to the use of override, or it may be that she was doing a very common action and it went wrong only because of other serious mistakes she made.

From a strictly patient safety standpoint, the minute details of this do matter. That's why it's a second, or third or fourth freaking crime that such things seem like they aren't even being looked into. You know - that, and well, the whole cover-up thingy.

[Emergent, RN]

18 minutes ago, LilPeanut said:

I believe she immediately went and got a new job at a different ICU at a different hospital. She was suspended there after all this came out.

Which is a failure of the current system of slow BON responses to nurses culpable in sentinal events.

When a police officer is involved in any on the job shooting in the line of duty, they pull him from active duty pending investigation.

Why should a potentially incompetent nurse be allowed to work until the BON gets around to the case months later?

That's like the Catholic Church moving predatory priests to a different parish. That's a poor practice.

[TriciaJ, RN]

48 minutes ago, Jory said:

Those questions are the very legal definition of reckless homicide. Have you ever taken a legal class even as an elective in college? If you have....then you would better understand this is not even hard.

This very definition has appeared in numerous articles on the topic as journalists have attempted to explain why THIS nurse, over others that have made medication errors and have not been charged, is being charged.

They are going to get a legal nurse consultant for her trial that is going to tell the jury that every nursing program teaches the five rights of medication and this is a universal standard. She will advise the jury every step RV bypassed for personal convenience. She is also going to advise the DA to have copies of all of her competencies pulled where she was checked off on medication administration, Pyxis training, pitfalls for avoiding errors in pulling the wrong medication, etc. They may even go as to so far as to get her college transcripts, her courses in pharmacology, anything tied to her certification, anything they can use to prove she was taught better.

If they move forward with the charges, there is no way they are not going to find her guilty. Her best bet is to keep the money she has got for GoFundMe, try to cut a plea deal to avoid a felony, give up her nursing license, and use that money to go back to college and major in something else.

I agree with this 100%. However our employers do keep adding on the stress and putting nurses between a rock and a hard place. Nursing schools really need to add courses on assertiveness and standing one's ground for patient safety. They talk a good game about being patient advocates; are they teaching courses that specifically address how to do this?

I'm not going to put a lot of energy into playing devil's advocate. I still firmly believe we are all 100% accountable for our own practice. But I really do hope modern hospital practices come to light so something good comes of all this.

[Corey Narry, MSN, RN, NP]

1 minute ago, Emergent said:

Which is a failure of the current system of slow BON responses to nurses culpable in sentinal events.

Does anyone know if it was even reported? if I'm not mistaken Vanderbilt did not make a report of a sentinel event (which this exactly fits the definition for that).

[JKL33]

Was this reported to the BON upon her termination?

[LilPeanut, MSN, RN, NP]

6 minutes ago, JKL33 said:

I don't know what to say. The whole quote regarding this is an ambiguous sentence or two from someone who may or may not ever touch patients or these machines, whose team performed an analysis.

Okay. I'll just quote the report (quote is from the MAPST, Manager of Adult Patient Safety Team, p.22):

My point is that we do not know the status under which the medication was ordered (STAT, NOW, Routine, PRN, etc). I have not been able to find that. She may have had reason to believe that it was entered as a STAT order since the patient was already down in radiology waiting for the med. But what we can't assume is that it wasn't entered STAT just because the situation was not in fact a dire emergency. It may indeed have been ordered STAT. She may have had reason to know that in such situations where the med is wanted sooner rather than later, it would be entered as STAT.

You see what I mean? So the wrong med pops up, somewhere on the screen is the override button, which has a warning saying it is for STAT orders. Given the perversion of the use of STAT/NOW order status, she very well may have believed that it was a STAT order.

Or she may have overlooked the 'red box' (whatever it was) like she overlooked everything else. ?

The thing is, aside from RV, if you (we all) are interested in keeping patients safe, it does matter how override is commonly used, off the record, in that facility. Not how I use it or how some other nurse uses it, but what the tenor of its use is in that facility. This could be a situation that was utterly out of the ordinary with regard to the use of override, or it may be that she was doing a very common action and it went wrong only because of other serious mistakes she made.

From a strictly patient safety standpoint, the minute details of this do matter. That's why it's a second, or third or fourth freaking crime that such things seem like they aren't even being looked into. You know - that, and well, the whole cover-up thingy.

The problem with that assumptionargument is that she had no idea whether it was ordered stat either. She never looked at a MAR. She took a verbal order for a controlled substance from another RN without any sort of checking.

I've never worked somewhere where we were expected to regularly override meds that were not emergent.

[TriciaJ, RN]

50 minutes ago, juan de la cruz said:

It was actually an order entered on Epic and it only took the Pharmacist a couple of minutes to approve the order. She went to the Pyxis about 10 mins after and would have seen it in the patient's profile if she took the time.

Not only that, but it may well have been loaded as midazolam and already been available when she looked for it. Per her statement she looked only for Versed.

[Emergent, RN]

1 minute ago, juan de la cruz said:

Does anyone know if it was even reported? if I'm not mistaken Vanderbilt did not make a report of a sentinel event (which this exactly fits the definition for that).

Well, there's another failure. I think it's evident that the hospital tried to cover this up.

But, eventually it did come out. This gal only got suspended from her new job when she was arrested.

[Jory, MSN, APRN, CNM]

6 minutes ago, JKL33 said:

Was this reported to the BON upon her termination?

If it wasn't, it should have been. God knows most places report for less.

[Susie2310]

1 hour ago, juan de la cruz said:

The CMS report is not detailed enough to prove that she is not distracted. She had an orientee and she was heading to the ED after carelessly finishing her task in Radiology.

I agree but I am seeing the situation from a Monday Morning Quarterback situation. I had a family member in a hospital recently but just in Step Down, I know mistakes happen and I did catch a few while there, they were not egregious or life threatening fortunately.

You posted the following on Jan 25 on another thread:

"A family member was in an ED and was subsequently admitted to a Tele Unit. As the family member present at the bedside, I have detected quite a few things that should not have happened and fortunately pointed it out to the nurses who were there to provide care. Examples such as double doing on anticoagulation medications, delay for hours of rate controlling medications for an arrhythmia, etc were all possibly attributable to being overworked but I was also careful not to embarrass or make the nurses involved feel intimidated."

Fortunately you, a NP, were at your family member's bedside and were able to catch the mistakes in time so your family member didn't suffer any harm. I think we are all familiar with the harm that can result to a patient from receiving a double dose of anticoagulants i.e. bleeding, intracranial hemorrhage, and to the harm that can result from multiple hour delays to receiving rate controlling medications for an arrhythmia e.g. heart failure, cardiac arrest. Fortunately your family member didn't suffer any harm because you were there by their side to advocate for them. Many patients (and their family members) are not as fortunate.

You can keep downplaying errors in care as much as you like. Perhaps if your family member had suffered a hemorrhagic stroke as a result of being overdosed with anticoagulants, or went into cardiac arrest or heart failure due to delays in receiving rate control medications, you would feel differently.

[BarrelOfMonkeys, BSN, RN]

This is truly a multi-level failure. It would seem the nurse and the institution failed the patient. Even if not agreeing to the same level of failure. I mean, who do you trust? As a patient? As an employee? Yikes.