Nurses Call the Governor of Tennessee

tiffanyselah · Feb 12, 2019

Why do we give them the bonuses for seeing a certain amt of patients in a day, but they don't share in the consequences? We alone share that burden, but together we share the money? nonsensical.

Horseshoe, BSN, RN · Feb 12, 2019

15 minutes ago, mtmkjr said:
@tiffanyselah you sound like a very conscientious nurse who cares a lot about the safety of your patients.
I think that before putting so much energy into posting here and sending off uninformed letters to the DA or whoever, you should see what the facts you are dealing with.
The facts are contrary to what you seem to believe about the case. For one thing, she did not have a patient load. No one told her to override anything that was her own recklessness
In addition, the posters here have acknowledged that there are system failures at play. However, there is no system failure that can account for the failure of this nurse to safely administer the drug she was giving to the patient.
Here is the CMS report.
https://www.wsmv.com/cms-report---vumc/pdf_a7ea6b5e-f41f-11e8-af7b-570ec9f22209.html

Unless that was addressed in the report and I just didn't catch it, it's possible that she had numerous calls for other patient interventions waiting for her attention such that she was stressed and hurried. Does that excuse not looking at labels or not monitoring a patient she believed had received IV Versed? No. But I'm not so sure that just because she didn't have the same kind of patient assignment as regular staff nurses, that she didn't still have a huge/unmanageable to-do list of calls for the resource nurse that she was feeling responsibility to answer. It might shed light on a hospital practice that could be addressed to prevent future less egregious, though still undesirable, outcomes.

Editorial Team / Admin · Feb 12, 2019

2 minutes ago, tiffanyselah said:
I responded already. She was the help-all. Doesn't explain asking a person to give a med in a scanner with no scanner for medications to check the right patient, right dose, no excuse for giving a patient a medication in a place with no appropriate monitors or resuscitation equipment, no excuse for constantly skipping pharmacy verification a NORMAL CONSTANT ER PROCESS. There is NO EXCUSE for pushing the responsibility solely on her. The administration can share in the consequences as well as the bonuses. period.

Medication scanning is an adjunct. It is not a replacement for laying human eyes on the label of the medication one is going to give. It is not a replacement for the 5 (or 7 or 8 ) rights of medication administration.

allnurses Guide · Feb 12, 2019

Your letter isn't really pertinent, unfortunately. There are MANY situations in which your letter is actually how things happen. However, that wasn't the case here.

She didn't have a patient load.

She overrode the Pyxis to pull the wrong drug.

She gave it without checking on the rights of medication administration.

She left the patient after giving the (wrong) drug. The drug she thought she was giving demanded monitoring. The one she actually gave was...well. Wrong. Gravely wrong. She should not have left the patient.

She is liable here. I hate to say that. I honestly do. Because it means one of our own failed this grossly. She is legally culpable. Often it isn't the case, but root cause analysis shows that she acted outside of normal scope with few of the reasons you name above as reasonable cause. This feels like it should give us, as nurses, a sounding board for the axe we have to grind but it just.....doesn't. This was a bad nurse. Advocating for our patients safety is our number one duty. She failed. She failed and someone died.

Editorial Team / Admin · Feb 12, 2019

2 minutes ago, tiffanyselah said:
Why do we give them the bonuses for seeing a certain amt of patients in a day, but they don't share in the consequences? We alone share that burden, but together we share the money? nonsensical.

Give who bonuses? I highly doubt you have read the CMS report. Please do and rethink your stance here- it is amazingly eye opening as to the egregious actions of this nurse. No physician told her to override the medication dispensing system. No physician told her to type 2 letters in and choose the first medication. No physician told her to skip looking at the label. No one told her to skip any of the vital steps in the medication administration process.

JadedCPN, BSN, RN · Feb 12, 2019

7 minutes ago, tiffanyselah said:
I responded already. She was the help-all. Doesn't explain asking a person to give a med in a scanner with no scanner for medications to check the right patient, right dose, no excuse for giving a patient a medication in a place with no appropriate monitors or resuscitation equipment, no excuse for constantly skipping pharmacy verification a NORMAL CONSTANT ER PROCESS. There is NO EXCUSE for pushing the responsibility solely on her. The administration can share in the consequences as well as the bonuses. period.

She had every opportunity to check the right patient and right dose, you don’t need a scanner for that. She admitted she didn’t even LOOK at the vial that she pulled! This was in the CMS report.

Also in the CMS report was the fact that the medications WAS verified by pharmacy. She couldn’t find it under “versed,” didn’t think/know to look under “midazolam,” so instead she overrode the medication, typed in VE, and admitted she just picked the first thing on the list.

Daisy4RN · Feb 12, 2019

@tiffanyselah

I agree with you that in principal nurses are pushed to act outside of safe practices on a daily basis and that is wrong!

In this case though, this nurse gave the wrong medication. She stated that she didn't even look at the vial prior to giving it. This was her mistake. I agree that the hospital should be held more accountable (than they were) because of environmental issues as well as trying to cover it up.

I don't see how the MD is to blame. He/she wrote the order for Versed but it was up to the nurse to administer it properly/safely, or refuse if unable to do that .

mtmkjr, BSN · Feb 12, 2019

24 minutes ago, tiffanyselah said:
I responded already. She was the help-all. Doesn't explain asking a person to give a med in a scanner with no scanner for medications to check the right patient, right dose, no excuse for giving a patient a medication in a place with no appropriate monitors or resuscitation equipment, no excuse for constantly skipping pharmacy verification a NORMAL CONSTANT ER PROCESS. There is NO EXCUSE for pushing the responsibility solely on her. The administration can share in the consequences as well as the bonuses. period.

Please, please read the report I linked. You do not know the facts of the case as they were recounted by the RN herself.

mtmkjr, BSN · Feb 12, 2019

26 minutes ago, Horseshoe said:
Unless that was addressed in the report and I just didn't catch it, it's possible that she had numerous calls for other patient interventions waiting for her attention such that she was stressed and hurried. Does that excuse not looking at labels or not monitoring a patient she believed had received IV Versed? No. But I'm not so sure that just because she didn't have the same kind of patient assignment as regular staff nurses, that she didn't still have a huge/unmanageable to-do list of calls for the resource nurse that she was feeling responsibility to answer. It might shed light on a hospital practice that could be addressed to prevent future less egregious, though still undesirable, outcomes.

Yes it's possible. But I don't think that's really relevant.

The pressure on someone who is assigned to the care of a particular patient who you are legally responsible is different than the pressure of a super-busy help all nurse.

Horseshoe, BSN, RN · Feb 12, 2019

6 minutes ago, mtmkjr said:
The pressure on someone who is assigned to the care of a particular patient who you are legally responsible is different than the pressure of a super-busy help all nurse.

Not sure I agree. If she is giving drugs or performing interventions, she is just as legally responsible for that action as any other nurse who gives a drug or performs an intervention. If she screws up and harms the patient with a med error, the patient's assigned nurse is not held accountable for the error.

Wuzzie · Feb 12, 2019

1 hour ago, tiffanyselah said:
IShould the charge nurse and administrators who did not allow for the right thing to happen also be prosecuted. I'm sure this nurse had an assignment. Was she in charge of 4 other people with orders piling up (responsibilities) while she was in radiology giving that medication? What about those patients? What if one of her patients in her room died of a massive heart attack because she was in radiology pushing a medication?
In most of the hospitals I've worked in there are no scanners in any radiology areas because patients don't get meds there, they get meds in their room. Why was she even asked to give a med in such a place? What there appropriate monitoring equipment in the room such as pulse ox, heart monitor? Was there a proper area for treatment if the patient coded? no, those things are in the room. This is why the patients should get meds in the room. Why was she even asked to give meds to a sick patient in a place where appropriate treatment could not be provided if the patient coded? Which they did.
Not that the nurse shouldn't be held responsible, but honestly so should the people who asked her to do such an irresponsible thing. The charge nurse and administrative personell hold rank above us nurses and ask us daily to do things that are illegal and when we refuse they laugh in our faces and ask someone else who doesn't know better or have the guts to say no. This is what should end. You can jail this person, but the mistake will continue to happen because it wasn't her bright idea. She was told to do this by a superior. She was told to BYPASS CHECKS by her superior! If she goes, those who meditated with her to commit this crime of bypassing checks should go with her.

If you’re going to post about this at least be accurate. Nobody TOLD her to bypass the checks. Nobody TOLD her to not do the 5 rights. She did that all on her own. I’m not sure where you’re getting your idea of how this went down but if you’d like to hear it in RV’s own words read the report. You can’t possibly have done so and come up with this.

And not sure where you work but radiology departments DO have emergency equipment. The patient was not sick.

mtmkjr, BSN · Feb 12, 2019

41 minutes ago, tiffanyselah said:
PET scan has no medication scanner, no scanner does - Check bypass #1, Scanners do not have appropriate equipment for a resuscitation which a code would require Check bypass #2 NO ONE in the ER waits for a pharmacist to verify meds EVER. That is an ER culture across the nation. BYPASS #3. I agree that she did make some errors. So she didn't have an assignment, you're right. But this practice of asking nurses to do this is a common practice. The fact that people aren't dying en masse of this is surprising actually because of all of these checks that are being bypassed. And more if I had more time to think about it. The reality is that nurses daily are bullied and pressured into NOT FOLLOWING THE RULES. As long as we continue to punish the minions and not those responsible for the orders we will never eradicate ourselves of this problem. What is the goal of jailing this woman? What is the goal? I'm sure we can find any reason to put her in jail, she's no angel, I'm sure. But if the goal is to rectify this issue of bypassing checks the responsibility needs to be pushed upwards. These administrators get to make so much money off of pushing us to do these things, why not share in the burden?

The fact that people aren't dying en masse is testament to the fact that nurses DO follow the safety checks.

Pharmacy had verified the med 10 minutes before she tried to get it out of the Pyxis.

She was not coming from the ER. She pulled the med in the ICU, put it in a baggie and labeled it with what she thought was the right med, but from start to finish she never looked to see what it was.