Nurses Call the Governor of Tennessee

allnurses Guide · Feb 14, 2019

4 hours ago, Anonymous865 said:
A couple of years ago there was discussion on AllNurses about a school bus driver in Chattanooga, TN who was driving too fast for the road conditions, lost control on a curve, left the road and hit a tree. Six children were killed.
That bus driver was charged and convicted of 6 counts of vehicular homicide which is the equivalent charge to reckless homicide. Both are involuntary homicide.
He was charged because he did not act in the way a reasonable, prudent person would and that action caused a death.
This bus driver did not intend to cause harm. He had no malice. Should the only punishment be loss of his CDL?
A truck driver lost part of his load on a highway. (I don't remember where this happened.) This resulted in the death of another person on the road.
He was charged with vehicular homicide because safety standards require a truck driver to inspect his load before getting on the highway. He did not load the trailer. Someone else loaded it and didn't secure it properly. If he had inspected his load before driving off, the accident wouldn't have happened and the other person would be alive
The trucker had no malice or intent. Should the only punishment be loss of his CDL?
In New Jersey a school bus driver missed his exit while driving students on a field trip. He attempted to make an illegal u-turn and the bus was hit. A teacher and a student died. He was charged with vehicular homicide because a reasonable, prudent person wouldn't have attempted the illegal u-turn.
The driver had no malice or intent. Should the only punishment be loss of his CDL.
This nurse was a highly trained professional. She bypassed not one, or two, or three, but many safety mechanisms that a reasonable, prudent nurse would not have done. (Not even reading the name on the drug she pulled!)
Shouldn't a highly trained professional be held to at least the same standards a a truck driver and school bus driver?

Good post and it does make me think.

Long Term Care Columnist / Guide · Feb 14, 2019

Anonymous865, you make an excellent point. I'm going to have to rethink my stance on whether or not the nurse should face criminal charges in light of your examples of other people who have made fatal mistakes. I still say she should lose her license, but maybe the penalties shouldn't end there. I wonder what her current workplace thinks about all of this?

Jory, MSN, APRN, CNM · Feb 14, 2019

12 hours ago, juan de la cruz said:
What made her do that in that specific instant is unanswered. Does she override non-urgent drugs often and was just lucky that she never in her short career ever pulled the wrong drug to give a patient? What made her intentionally ignore the drug label yet follow the instructions of reconstituting the drug? Has she always been that careless by not watching a patient for the effects of medications she administered intravenously? What was going on in her mind when she was mixing the drug? I don't know how Nurse RV is like as a nurse and with that element of doubt I can't say to her one error and you're going to jail despite the egregious nature of her actions.

Oh, I can answer that for you...laziness.

Now, if this was her habit...we don't know. But I'm sure the DA will investigate that matter. Because she didn't make one error...not even close. The DA doesn't say that and neither does the CMS report. She made multiple, deliberate, errors.

Advanced Practice Columnist / Guide · Feb 14, 2019

All cases of medication error involves a nurse recklessly omitting a step in the medication administration process and a big percentage of the cases based on available data suggests that one or more of the 5 rights were ignored leading to the adverse consequence. It's understandable to feel outrage at how Nurse RV acted but her careless act was no different than the others who have committed similar fatal mistakes. Take for instance this one:

https://abcnews.go.com/Health/nurse-patient-paralytic-antacid/story?id=14997244

and the subsequent BON decision (the RN license is still active):

https://appsmqa.doh.state.fl.us/MQASearchServices/Document/MTQyMDk1MjI%3d

The next of kin sued the hospital and presumably naming the nurse as well in the civil suit but it likely led to a settlement. I couldn't find any information on the details. This case met criteria for involuntary manslaughter in Florida but was never charged with this crime.

Advanced Practice Columnist / Guide · Feb 14, 2019

2 minutes ago, Jory said:
Oh, I can answer that for you...laziness.
Now, if this was her habit...we don't know. But I'm sure the DA will investigate that matter. Because she didn't make one error...not even close. The DA doesn't say that and neither does the CMS report. She made multiple, deliberate, errors.

I agree.

Jory, MSN, APRN, CNM · Feb 14, 2019

3 hours ago, juan de la cruz said:
Yes, this is a go at this point and she is facing trial. I'm hoping just like everyone else that we do get the answers we want. Given the kind of publicity she is getting and the go fund me page that is generating monetary support, I hope that lawyers on both sides will strive for upholding the truth and justice will be served.
If anything, this case will make nurses more aware of paralytics, at least the ones who are following it. Next time, it's going to be another drug that is going to be mixed up with the wrong drug by an inattentive nurse. We need to continue to strive for ways to overcome the pull of human error from providing safe care to patients.

Whoa..Nelly....

You think this is a case about paralytics? Well, it's not.

She also didn't make a human error. You are mad about being misquoted...well, this is what you typed..human error. If I deliberately make a choice to do something that is against policy over and over again...is that human error or is that just me trying to get away with taking a shortcut?

She also didn't get the drugs mixed up....have you even bothered to read the CMS report?

A 10 year old could have done better. She wants to find Versed, she doesn't find Versed, she puts in only two letters and clicks the first thing she sees that ISN'T EVEN CLOSE to Versed and meh...calls it good.

I don't think you truly understand the deliberate nature of her actions.

Jory, MSN, APRN, CNM · Feb 14, 2019

8 hours ago, juan de la cruz said:
My point is, we are not prosecuting all of these cases in criminal court. We also don't know the details of each of these cases to even know how they compare to Nurse RV's case. Some are probably even more egregious. You are saying that we must prosecute Nurse RV for the crime she committed, my question is what about those other cases that did not get a spotlight in the media? Prosecuting healthcare professionals who have committed a negligent act resulting in death has not traditionally been held in criminal court for reasons in my opinion that the risk is inherent in our profession.

Uh...do you even KNOW why the DA is charging her? Specifically? It's important you understand the reason she is being charged. I have a feeling you don't.

Advanced Practice Columnist / Guide · Feb 14, 2019

24 minutes ago, Jory said:
Whoa..Nelly....
You think this is a case about paralytics? Well, it's not.
She also didn't make a human error. You are mad about being misquoted...well, this is what you typed..human error. If I deliberately make a choice to do something that is against policy over and over again...is that human error or is that just me trying to get away with taking a shortcut?
She also didn't get the drugs mixed up....have you even bothered to read the CMS report?
A 10 year old could have done better. She wants to find Versed, she doesn't find Versed, she puts in only two letters and clicks the first thing she sees that ISN'T EVEN CLOSE to Versed and meh...calls it good.
I don't think you truly understand the deliberate nature of her actions.

Wait a minute, you don't have to be condescending to get your point across. Yes, I read the CMS report many times. When I said "getting the drugs mixed up", I wasn't specifically talking about Nurse RV's case. I am aware of multiple other cases of medication errors and in many cases, the nurse got the drugs mixed up. That post is an answer to how medication errors will continue to happen regardless of the outcome of this case because of systemic failures and "human errors" - I stand by that phrase, that creates this lethal combination. I was giving you slack for calling a person you don't know lazy. Settle down, no one is making you mad for not agreeing with you.

Advanced Practice Columnist / Guide · Feb 14, 2019

19 minutes ago, Jory said:
Uh...do you even KNOW why the DA is charging her? Specifically? It's important you understand the reason she is being charged. I have a feeling you don't.

Do you? The Tennessee Bureau of Investigation documents aren't public unless you've seen it somewhere. You're just going by the CMS report which is hardly thorough.

Jory, MSN, APRN, CNM · Feb 14, 2019

10 minutes ago, juan de la cruz said:
Do you? The Tennessee Bureau of Investigation documents aren't public unless you've seen it somewhere. You're just going by the CMS report which is hardly thorough.

It is in several news reports. The whole reason they are charging her is because she intentionally bypassed MULTIPLE checks.

That is why you don't see these cases in the news every day or multiple nurses charged. Most nurses that make a medication error may fail on one, even two...but not as many as RV did.

This case is different because what she did WAS DIFFERENT.

https://www.tennessean.com/story/news/health/2019/02/06/vanderbilt-nurse-vecuronium-versed-patient-death-radonda-vaught/2795475002/

Advanced Practice Columnist / Guide · Feb 14, 2019

6 minutes ago, Jory said:
It is in several news reports. The whole reason they are charging her is because she intentionally bypassed MULTIPLE checks.
That is why you don't see these cases in the news every day or multiple nurses charged. Most nurses that make a medication error may fail on one, even two...but not as many as RV did.
This case is different because what she did WAS DIFFERENT.

Wow, you're using news reports to make a judgement. I know she bypassed multiple checks. A nurse who in her mind thinks she has Versed in her hand will bypass checks. That's what human error is. You can say she is a criminal all you want. I won't.

Jory, MSN, APRN, CNM · Feb 14, 2019

10 minutes ago, juan de la cruz said:
Wow, you'e using news reports to make a judgement. I know she bypassed multiple checks. A nurse who in her mind thinks she has Versed in her hand will bypass checks. That's what human error is. You can say she is a criminal all you want. I don't.

Oh wow...you really don't get it do you? So even after I supply a source you still don't get it. Honey...it's not a rush to judgement. It is a FACT she is being charged b/c she bypassed multiple safeguards.

So tell me...exactly what made her think she had Versed in her hand when Versed never came up on the screen? She never found Versed? She didn't even enter Versed?

There was even a warning that said the drug she selected was not to be pulled without a stat order.....she didn't have a stat order.

She bypassed that too.

What she did is criminal....when you are going to bypass the computer system YOUR ACTIONS take the place of that computer. At minimum you can at least enter the correct drug name and look at the vial when you pull it out...but well, she didn't do that either.