Nurses Call the Governor of Tennessee

Published

The state of TN is prosecuting nurse Radonda Vaught for reckless homicide. You can contact the Governor or DA to let him know what you think about this choice.

Governor Bill Lee

1st Floor, State Capitol
Nashville, TN 37243
(615) 741-2001
email: [email protected]

District Attorney Glenn Funk

Specializes in ACNP-BC, Adult Critical Care, Cardiology.
12 minutes ago, JKL33 said:

These fake emergencies like the PET scan, the IV med for the downgraded ICU patient off monitors in an outpatient department, the swallow screen in the ED - unfortunately not one of these was even an urgency.

I would actually accept a nurse mouthing off to me and saying that they can't come down to Radiology to give Versed and that my patient's PET scan would have to be cancelled because they're too busy. I might roll my eyes but I'd still say "umm OK". Fortunately, I'm in an environment where an attending won't be throwing a hissy fit at me for allowing a nurse to cancel a test they wanted if I say it's for safety.

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I'm totally immune to all of that and have been for a long time. And, if you develop a sympathetic/kind yet determined manner of saying no >> very few problems.

"Oh, I'm sorry and I know it's going to throw your schedule off, but we actually can't do that. Please send her back up." [Or whatever. Maybe a nurse would have chosen to take a portable v/s machine down there or something.]

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Specializes in Psych (25 years), Medical (15 years).

I ask myself, "How could this happen?" when so many plain-as-the-nose-on-your-face safeguards didn't stop it from happening.

We here at allnurses lost a respected leader some years back to a tragic and heinous death and we asked ourselves, "How could this happen?"

This is the only reasonable rationale that I can fathom:

Once some electrochemical processes undergo potentiation, the process will continue on its way and logical conscious thought or hell and high water will not deter its course.

Of course that means anybody at anytime could be the world's greatest hero or the lowest of lows scoundrel.

There for the grace of God go I.

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On 2/10/2019 at 11:41 PM, juan de la cruz said:

Could we have a legal expert weigh in on this? I've looked into criminal prosecution of nurses who have committed medication errors and it seems like the first case in the US occurred as far back as 1998 in Colorado. I no longer could find a decent link to the events surrounding that case aside from this one:

https://www.researchgate.net/publication/290856623_Lesson_from_the_Denver_medication_errorcriminal_negligence_case_Look_beyond_blaming_individuals

...also, there was a medication error involving a nurse in Wisconsin in 2006 that also led to criminal charges and I found details of it in this link:

http://asq.org/qualitynews/qnt/execute/displaySetup?newsID=1056

What struck me about those cases was that the nurses involved struck a plea deal and did not get jail time except one nurse in the Colorado case who had a hearing in court and was acquitted by a jury. None of the nursing licenses were revoked though they all faced disciplinary sanctions after their respective BON investigations concluded.

I also came upon a phenomenon called "Inattentional Blindness" which is apparently a thing making it even more important that we have layers of safeguards in place (i.e., not overriding non-emergent meds, bar code scanning) because having the "5 rights" drilled in our brains apparently doesn't always work. More info on that here:

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3474444/

The Vanderbilt case is strikingly similar but we are in a day and age when technological advancements exist to allow multiple layers of safeguards yet they were blatantly ignored. I wonder how that would play in the outcome.

Also read:

https://www.nursingcenter.com/cearticle?an=00128488-200901000-00003&Journal_ID=260876&Issue_ID=848807#P32

Fascinating read, by the way, on the inattentional blindness phenomenon. It would seem to be a real challenge to manipulate the healthcare environment as we’ve shaped it today to reduce demands on a person to be able to increase conspicuity of critical info and therefore better the health outcomes of patients. I’m going to research this more. Thanks for sharing it.

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Specializes in ACNP-BC, Adult Critical Care, Cardiology.
4 minutes ago, BarrelOfMonkeys said:

Fascinating read, by the way, on the inattentional blindness phenomenon. It would seem to be a real challenge to manipulate the healthcare environment as we’ve shaped it today to reduce demands on a person to be able to increase conspicuity of critical info and therefore better the health outcomes of patients. I’m going to research this more. Thanks for sharing it.

This video actually illustrates the concept:

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4 minutes ago, juan de la cruz said:

This video actually illustrates the concept:

Great illustration! I was off by one and didn’t even notice the last piece. Ugh.

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10 hours ago, MJP79 said:

Ironic that you mistakenly typed Versed instead of Vecuronium.

You need to re-read it. I wrote it in the sense of the medication she thought she gave. Yes it was actually Vecuronium but she slammed what she thought was Versed and walked away. You don't give Versed that way. So no irony at all.

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10 hours ago, juan de la cruz said:

Just wanted to say to @tiffanyselah, you are still much welcome to chime in this discussion. I apologize in advance if there might have been a whiff of condescension from those of us who just feel as strongly about this case as you do.

I wasn't meaning to be condescending. Her facts were wrong, her examples were...indelicate. It was not a great representation of nursing and if I was the DA I would have been ticked off at many of the things she said about me.

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Specializes in NICU/Neonatal transport.

There were additional errors she made that people haven't even added to her count:

* She never looked at any MAR. She essentially took a verbal order for a controlled substance from a nurse without any verification of the order, and did not confirm the dosage or drug (where she would have seen that it was called midazolam) via the MAR prior to going to the pyxis.
* There was an orange neon sticker on the drawer that said "WARNING, PARALYTIC" on the drawer, that she didn't notice, along with the band around the vial and the warning on the cap.

Other people have discussed the dismissal of the override warning.

* She didn't notice that versed, which is a *controlled substance* should require 2 people to take out of the pyxis did not. That should have been a red flag as well.
* She didn't follow safe handling procedures for drawing up and wasting a controlled substance, if she thought it was versed. You do not waste your controlled substances hours later after they have been in your possession in a vial for a long period of time (a nurse could have swapped out the drug for saline in that time). You draw up the drug (two doses if that is the total possible order) and waste the rest immediately and if you don't use the second dose, you waste that after. Still not the best, but far better than taking the whole vial.
* She did not label any of the syringes. You do not draw up drugs into syringes and not label them, especially when you are carrying them around with other unlabeled syringes of liquid (flush).
* She had no idea how much she gave. She thinks 2 ml. But she isn't sure. And since none of the syringes were labeled, no one could be sure.
* The order was actually for 1 mg, and then if anxiolysis wasn't achieved, to give the second 1 mg dose. Which she didn't do.
* She didn't document immediately the administration. The MAR would have shown the vec override and maybe that would have caused her to go back and check on the patient. While radiology didn't have a scanner, she could have documented it manually from any other computer.
* She was doing all of this incredibly reckless behavior in front of an orientee, a time when you should be modeling picture perfect practice.

Regarding the lack of reporting to the ME - from reading the CMS report, it seems to me that perhaps the doctor was trying to hedge and not "tattle" on the nurse, because of the white line you see many people here exhibiting of trying to protect their own. It's not acceptable when cops do it, it's not acceptable when medical professionals do it.

My feeling is that perhaps the charges were filed because the BON didn't take any action against her license, and filing charges was the only way to get her license permanently removed.

I can't believe honestly that she's still working in an ICU environment. In that WI case, they at least restricted the RN to not working in an acute environment and needing heavy supervision and not being allowed to work overtime.

We all make mistakes, the system is designed to catch those mistakes. The swiss cheese model is built on the idea that lots of different people can make little mistakes and if they all line up, they reach the patient. It's not that one person is grossly negligent and takes a drill out and puts holes in cheddar. There is a reason we are educated and licensed and trusted and why PCAs, family or joe smith off the street does not administer medication. We are part of the safety process and if we are purposefully being unsafe (as this nurse was) there is no amount of systems that can fix that, besides removing that person from ever being a nurse again.

This was not a mistyped number, a misread zero, a wrong box clicked, etc. This was absolutely no attempt to follow any nursing process, deliberately overriding and ignoring warnings. Overrides may sometimes be necessary, but in those rare cases, it is even more essential to double, triple check the medication, the MAR and have someone else check it with you. Because you're moving outside the systems.

Someone mentions pilots not getting prosecuted unless they are impaired - yes and no. If the pilot were to deliberately disregard the safety checklists and say "screw it, I'm in a hurry so we can get out on time because I want to go on vacation", I have a feeling they would hold them responsible. I just haven't heard of a pilot deliberately ignoring safety procedures, it's just usually finding procedures that didn't account for a problem that occurred.

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Specializes in ER.

You make an interesting point @LilPeanut regarding whether the prosecutor was trying to accomplish what the BON failed to do. I agree, it's unbelievable that Radonda has been still working under an unencumbered license.

You make many excellent points.

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I also find it interesting that to this day as far as I can tell, there is no documentation in the eMAR that any medication was given.

When she went into the patient's ICU room to let the physician and NP know that she had given the patient vecuronium instead of versed, they asked her if it had been documented. That may have simply been out of disbelief that such an error could be made within the system.

At that point I believe management/administration must have directed her not to document anything at all because the intent from that point on was to cover up, as they successfully did for the next year.

I can't remember... how did this finally reach CMS?

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On 2/11/2019 at 5:13 AM, Jory said:

(no quote intended, charleefoxtrot made a mistake and clicked on the quote button and can't figure out how to clear the quote box now sorry Jory)

I have read all the replies, and had my opinion swing back and forth until I realized that a lot of my feelings were "Here but the grace of God go I." meaning that I have made medication errors throughout my career and therefore had built in empathy for the Vanderbuilt RN. I told myself after all, there wasn't any intent on her part, right? So why criminally charge her?

But really thinking about this case, and the statute calling for a homicide charge my mind began to shift. When she bypassed multiple safety checks (again, here but for the grace of God go I as I myself have overridden system checks in a similar fashion - no error made though) that moved this from the realm of a mistake to criminally negligent.

Posters here have drawn the analogy of a drunk driver, I don't think that is correct. I more think it is like the tainted steroid case from several years ago where management at a manufacturer consciously bypassed safety regulations and procedures which caused people to die from contaminated steroids. Those executives were criminally charged for their part in those deaths. So how is an RN bypassing multiple safety checks any different?

So yes, given what I have read I have to say I agree with the DA's decision to charge. Let the courts figure out if she is guilty of that charge and if so what an appropriate punishment would entail. Thankfully I am not in that jury pool.

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