Nurses Call the Governor of Tennessee

Advanced Practice Columnist / Guide · Feb 13, 2019

4 minutes ago, mtmkjr said:
I have observed over the years nurses who take pride in being super-confident and efficient at the expense of safety.
That appears to be the message the orientee was getting here.
That can be very intimidating to the new nurse whose sensibilities are being attacked in being told, "This is how we do it."

I feel that the orientee maybe is none the wiser if he/she was witnessing the whole thing. If it was someone who's more attuned to or "in the moment" in terms of knowing what was going on, they would have said "girl, you're about to give a paralytic!".

Susie2310 · Feb 13, 2019

On February 10, 2019 at 10:58 AM, Susie2310 said:
Medication errors can also be the result of nurses choosing to bypass basic medication administration safety procedures (Five Rights) and other checks; in which case a nurse's "errors" are due to a choice (selection) the nurse made which would be below the Standard of Care a licensed professional nurse is held to, and not due a mistake (poor judgement). Also, not all medication "errors" are due to "systems errors." Licensed nurses have individual legal and professional responsibility for safe medication administration and are held individually accountable for meeting legal and professional standards of care by their State Boards of Nursing.

Re-reading this again I want to clarify the above to say that mistakes in care can also reflect care that is below the Standard of Care, for example where a nurse by virtue of his/her training would be expected to possess the knowledge to use good judgement and not to use poor judgement in providing care, but uses poor judgement and practices below the Standard of Care.

TriciaJ, RN · Feb 13, 2019

2 hours ago, mtmkjr said:
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?

I read somewhere that at some point "someone" reported it. I'm betting it was someone at Vandy who realized the whole thing was being swept under the rug and blew the whistle.

TriciaJ, RN · Feb 13, 2019

1 hour ago, juan de la cruz said:
I'm sure the med error was passed by the providers to each other during sign out, how can it not be. It would have made my jaw drop if I were the NP that was told that. It sounds like Vanderbilt uses Epic for EMR and we do too where I work. I've completed death documentation on Epic and if theirs is similar to ours, you go through a checklist of questions that prompt you to call the ME if you said yes to any of the questions, one being if the death was a result of a med error.

I think this event was just before they rolled out Epic at Vandy. Not clear what system they were using at the time.

Jory, MSN, APRN, CNM · Feb 13, 2019

2 hours ago, Emergent said:
The video by the YouTube doctor compared this case to the NP who left her baby in her car on a hot day at work. It's the danger of being on autopilot.
I personally think it's more common in our modern age. For instance, all the warnings, steps, computer processes definately cause me to be less focused on the here and now, and more focused on the technology that often seems like an obstacle course to navigate through.
I remember the days of paper MARs and a simpler process that allowed me to be more thoughtful.

I actually know someone personally who had a baby die from leaving it in the car. She was going on several days of severe sleep deprivation and a detour due to construction that would have originally had her backtracking her route (a road she would have been on only AFTER) she dropped the baby off made her think she did drop it off. She found her baby when she was putting some things in the back seat. He had been asleep that morning. It was horrible.

But she only forgot ONE thing (though significant and tragic) and didn't even intentionally forget to drop her baby off at daycare.

Not the case with this nurse.

She intentionally did the override for the drug, bypassed warnings she had to hit a button to clear, and didn't do any of the five rights other than check the patient's name.

So it's not even close to a hot car death...not even close.

I was the one that wrote the similarity to the drunk driver. Yes, it is similar. Many people don't realize they have had too much when they get behind the wheel, especially if they have only had two or three drinks, as alcohol impacts everyone differently.

So...you know, in advance, BEFORE you get behind of the wheel, that drinking and driving is dangerous, should you be impaired it's illegal, and if you don't kill someone...you just get a DUI...not a felony..but if you kill someone, you get charged with something very different.

So the drinking is an intentional choice, the drinking and driving, is an intentional choice, but killing someone? Zero intent...but you still know that is a risk when you get behind the wheel.

Failing to even LOOK at the medication you are pulling out and bypassing every safety check is an intentional choice. Killing the patient isn't.

It's the exact same thing.

Advanced Practice Columnist / Guide · Feb 13, 2019

1 minute ago, TriciaJ said:
I think this event was just before they rolled out Epic at Vandy. Not clear what system they were using at the time.

That's right...and I'm probably going by the fact that our Epic charting closely follow California regulations for death reporting. Our Epic questionnaire is the exact copy of the paper form required by the state.

Jory, MSN, APRN, CNM · Feb 13, 2019

4 hours ago, Emergent said:
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.

The reason she has been working under an unencumbered license is because she hasn't been found guilty of anything nor has there been a BON hearing.

I know of someone that recently made the paper and was arrested for something she did in association with her nursing license and her nursing license is showing as crystal clear with the state.

That's because, she hasn't had her trial yet. Under the law, she hasn't been convicted of anything.

TriciaJ, RN · Feb 13, 2019

1 hour ago, mtmkjr said:
From this article:
Support Grows for Ex VUMC Nurse Charged With Reckless Homicide

Turning up in scrubs to show their support? Have they actually thought about what they're supporting? Some people will mindlessly jump on any bandwagon, will lend their support to anything. Sickening.

I support safe and prudent nursing practice. Not infallible. Just conscientious.

Wuzzie · Feb 13, 2019

10 minutes ago, Jory said:
Failing to even LOOK at the medication you are pulling out and bypassing every safety check is an intentional choice. Killing the patient isn't.

This about a billion times. No she didn't intend to kill the patient but she most certainly made a choice to do everything else she did and did not do.

Advanced Practice Columnist / Guide · Feb 13, 2019

5 minutes ago, TriciaJ said:
Turning up in scrubs to show their support? Have they actually thought about what they're supporting? Some people will mindlessly jump on any bandwagon, will lend their support to anything. Sickening.
I support safe and prudent nursing practice. Not infallible. Just conscientious.

Lol...which reminds me of an immature act we did when we were students to protest clinical instructors who we felt were too cruel...we demanded a meeting with the dean and the females had their nursing caps on as a statement. Guess what, the dean was like "get those #%$# nursing caps off your heads!".

Jory, MSN, APRN, CNM · Feb 13, 2019

2 minutes ago, TriciaJ said:
Turning up in scrubs to show their support? Have they actually thought about what they're supporting? Some people will mindlessly jump on any bandwagon, will lend their support to anything. Sickening.
I support safe and prudent nursing practice. Not infallible. Just conscientious.

She's also raised a ton of money on Gofundme. I guarantee 99.9% of the people showing up to support her hasn't even read the CMS report to see the full impact of what she did.

My thought is this.....

People need to stop saying, "Oh, this happened because she was inexperienced"...no, 3 1/2 years is not inexperienced. We start training nurses to take charge around two years in.

A brand new grad would not have made this mistake because they would have been so paranoid of giving the wrong drug they would have made sure every checkpoint was completed and they would have asked for a second set of eyes if there was any doubt.

Jory, MSN, APRN, CNM · Feb 13, 2019

8 minutes ago, juan de la cruz said:
Lol...which reminds me of an immature act we did when we were students to protest clinical instructors who we felt were too cruel...we demanded a meeting with the dean and the females had their nursing caps on as a statement. Guess what, the dean was like "get those #%$# nursing caps off your heads!".

Well, this is off topic...but it really isn't immature. Clinical instructors are supposed to teach...it is not their time to belittle or humiliate students. It is not their time to see how sarcastic, arrogant, or condescending they can be or how much they can tear students down. Spending the whole class talking about "me, me, me me me". They are there to support, guide, direct.

If you can't do that professionally and with compassion, then you have no business in the teaching profession.

Want to know WHY bullying is so prevalent in the profession of nursing that the Joint Commission has listed it as impacting patient care?

It starts in nursing school. Universities and colleges need to stop tolerating the behavior and so do hospitals. I have zero tolerance for this in other nurses and will call them out on it in a heartbeat.