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Nurses Call the Governor of Tennessee

Nurses   (16,460 Views 422 Comments)
by Nurse Beth Nurse Beth, MSN (Advice Column) Writer Innovator Expert

Nurse Beth is a MSN and specializes in Med Surg, Tele, ICU, Ortho.

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You are reading page 29 of Nurses Call the Governor of Tennessee. If you want to start from the beginning Go to First Page.

juan de la cruz is a MSN, RN, NP and specializes in APRN, Adult Critical Care.

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9 minutes ago, Jory said:

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. 

Quit your patronizing attitude.

Oh, so now you're telling me she intentionally injected vecuronium? I'm confused. She entered VE on the Accudose and thought she pulled Versed out of the cabinet and didn't bother to check the label. She mixed the drug and thought she was mixing Versed. She gave the drug she thought was Versed and walked away.

There is a phenomenon called inattentional blindness, look it up. BTW, Do you know what would happen to this patient if she got Versed instead of vecuronium? how many ICU nurses give Versed 1 mg IV and walk away from the patient? it's not the standard of care but it happens and I've seen others do it with no consequence. Get your emotions out of this discussion.

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8 minutes ago, juan de la cruz said:

Quit your patronizing attitude. Oh, so now you're telling me she intentionally injected vecuronium? She entered VE on the Accudose and thought she pulled Versed out of the cabinet and didn't bother to check the label. She mixed the drug and thought she was mixing Versed. She gave the drug she thought was Versed and walked away. Do you know what would happen to this patient if she got Versed instead of vecuronium? How many ICU nurses give Versed 1 mg IV and walk away from the patient? it's not the standard of care but it happens and I've seen others do it with no consequence. Get your emotions out of this discussion.

First....you denied a source existed for WHY SHE WAS CHARGED, I proved you wrong and the person that started with the patronizing attitude was  you.

You get what you give. 

Second...copy and paste where I stated she gave vercuronium intentionally.  You clearly did not read what I wrote.

If you are looking for Versed and you put in Ve and Vecuronium shows up on the screen (Versed never appeared, per the CMS report)...exactly what part of that makes you think it's Versed?   

If she had actually FOUND Versed in the Pyxis and PULLED vecuronium by accident because it was in the same cabinet...that would be more understandable...but even then...she would have two opportunities to catch it:  1.  Look at the vial or 2.  Scan it...she didn't do either one of those either.  

My emotions are not in this discussion, but factual information doesn't seem to mean very much to you...there is apparently no limit to the amount of deliberate negligence you are willing to tolerate in the nursing profession.  Ever heard of nurse serial killers?  This is why they can take out a couple of floors before they actually get fired or arrested because there is too many people willing to keep giving a pass.  

Edited by Jory

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juan de la cruz is a MSN, RN, NP and specializes in APRN, Adult Critical Care.

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21 minutes ago, Jory said:

First....you denied a source existed for WHY SHE WAS CHARGED, I proved you wrong and the person that started with the patronizing attitude was  you.

Patronizing = condescending, using endearing words such as "honey" to be insulting. I'll just say I don't rely on news items. I don't necessarily feel that the bypasses are relevant in a nurse who is so distracted to even think that she is not committing an error.

 

21 minutes ago, Jory said:

You get what you give.

What am I giving exactly?

21 minutes ago, Jory said:

Second...copy and paste where I stated she gave vercuronium intentionally.  You clearly did not read what I wrote.

Yeah you didn't write that.

21 minutes ago, Jory said:

If you are looking for Versed and you put in Ve and Vecuronium shows up on the screen (Versed never appeared, per the CMS report)...exactly what part of that makes you think it's Versed?

She wasn't paying attention, maybe distracted, that's the whole premise of this medication error.

 

21 minutes ago, Jory said:

If she had actually FOUND Versed in the Pyxis and PULLED vecuronium by accident because it was in the same cabinet...that would be more understandable...but even then...she would have two opportunities to catch it:  1.  Look at the vial or 2.  Scan it...she didn't do either one of those either.  

You're preaching to the choir. I'm not Nurse RV and this egregious mistake would never happen to me. I give moderate sedation to patients for procedures all the time. You don't have to agree with my opinion because I sure don't agree with yours.

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juan de la cruz is a MSN, RN, NP and specializes in APRN, Adult Critical Care.

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14 minutes ago, Jory said:

My emotions are not in this discussion, but factual information doesn't seem to mean very much to you...there is apparently no limit to the amount of deliberate negligence you are willing to tolerate in the nursing profession.  Ever heard of nurse serial killers?  This is why they can take out a couple of floors before they actually get fired or arrested because there is too many people willing to keep giving a pass.  

Deliberate is subjective...did she deliberately give vecuronium? She is not a serial killer, at least not that we know.

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8 minutes ago, juan de la cruz said:

Deliberate is subjective...did she deliberately give vecuronium? She is not a serial killer, at least not that we know.

When you bypass seven different safety checks....yes, that is a deliberate action.  Which is why she is being charged.  

Forget RV...the bottom line is there is no threshold for nursing standards where you would ever think a nurse should be criminally charged.  No combination of choices.  Other professions/industries are charged/jailed all the time.  I guess you think nursing should get a pass.  Go ahead, be as reckless as you want...kill as many people as you want...in the end, you get a pass. 

Edited by Jory

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juan de la cruz is a MSN, RN, NP and specializes in APRN, Adult Critical Care.

3 Followers; 8 Articles; 3,840 Posts; 58,306 Profile Views

4 minutes ago, Jory said:

When you bypass seven different safety checks....yes, that is a deliberate action.  Which is why she is being charged.  

Forget RV...the bottom line is there is no threshold for nursing standards where you would ever think a nurse should be criminally charged.  No combination of choices.  Other professions/industries are charged/jailed all the time.  I guess you think nursing should get a pass. 

Oh she needs her license revoked and should never practice as a nurse again. Go to jail? nah. What are we rehabilitating her for? laziness? murder? She's not going to recover emotionally from this and her future is probably screwed from the scars of this ordeal. That's punishment enough.

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juan de la cruz is a MSN, RN, NP and specializes in APRN, Adult Critical Care.

3 Followers; 8 Articles; 3,840 Posts; 58,306 Profile Views

8 minutes ago, Jory said:

Go ahead, be as reckless as you want...kill as many people as you want...in the end, you get a pass. 

Oh you edited. Really? your original comment is still up there.

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juan de la cruz is a MSN, RN, NP and specializes in APRN, Adult Critical Care.

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I sure would want to sign up for a medication error prevention committee at work. Hey, it's an interesting research topic. I'd love to help keep my units at work safe and up to standards.

https://www.ismp.org/resources/safety-enhancements-every-hospital-must-consider-wake-another-tragic-neuromuscular

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On 2/10/2019 at 10:28 AM, Nurse Beth said:

Thank you!

For those who want to contact DA Glenn Funk who brought charges, here is the contact info link. Scroll down and there's an easy field to send an email from this page. I did it in 10 seconds.   Just think if hundreds of nurses sent an email.

I just did right before go to work. We need to prevent her from going to jail because this can be one of us in this complex profession that is in constant demands.

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1 hour ago, juan de la cruz said:

Quit your patronizing attitude.

Oh, so now you're telling me she intentionally injected vecuronium? I'm confused. She entered VE on the Accudose and thought she pulled Versed out of the cabinet and didn't bother to check the label. She mixed the drug and thought she was mixing Versed. She gave the drug she thought was Versed and walked away.

There is a phenomenon called inattentional blindness, look it up. BTW, Do you know what would happen to this patient if she got Versed instead of vecuronium? how many ICU nurses give Versed 1 mg IV and walk away from the patient? it's not the standard of care but it happens and I've seen others do it with no consequence. Get your emotions out of this discussion.

I love you.... Amen to this quote

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LilPeanut is a MSN, RN, NP and specializes in NICU/Neonatal transport.

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19 hours ago, mtmkjr said:

You don't think so? I don't think the provider had a say in how nursing actions were documented...(I don't disagree that they would try to protect the nurse if they could)

I could be wrong, but I think it was in the hands of administration at that point.

That allowed them not to report, just let it sit there as a death d/t brain bleed.

But it was in the hands of the physicians when they reported to the ME whether they reported the med error.  The physician calls the ME's office when a patient passes.

19 hours 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'm sure it was - but that's where the provider probably got the "hearsay" aspect, it was passed along in report, much like gossip, without any formal process. The doc should have been honest and reported it as a med error, but it sounds like it had been passed along in report but not a formal finding of error, so the doc didn't want to be the first to codify it as "for sure" and nail the coffin shut. They could have been afraid of blowback possibly from administration for admitting to the error outside the institution, but we don't know. That will likely be discussed in trial. 

18 hours ago, Wuzzie said:

Didn't you find it disturbing that she wasn't even sure how much she gave when she thought it was Versed? She said she followed the instructions on the vial. That makes it a 1mg/1ml concentration (yes I know it wasn't actually Versed but she thought it was) The math is not difficult. She pushed 2ml (or potentially 8 but I doubt that) so 2mg. Two problems with that. It was supposed to be 1mg and she didn't know how much she pushed. Was she just being evasive.

There were two syringes of "normal saline", one had vec, one had saline, neither was labeled, so there was no way to know which had the vec in it.  She could have even made an additional error with switching the flush with the drug, we don't know, she doesn't know.  It was an incredibly careless way to handle the medication, no matter what medication it was. 

16 hours ago, Horseshoe said:

I think they should lose their license and the ability to ever work in healthcare again and pay restitution to the family to the degree that that they can. And of course, in this day and age, lose the ability to ever walk away from that negligence or hide behind anonymity because their act was made public far and wide in news reports and internet. Their ability to harm another human being in a medical setting is eliminated and their life is basically ruined. They just aren't sitting in a jail cell for years or decades.

Sometimes criminal charges are the best way to ensure that. It can be easier to slip through the cracks and get a license somewhere else if a felony conviction isn't popping up on your background check.

The kind of homicide she is charged with has no mandatory jail sentence and typically it comes with a suspended sentence and probation, meaning that as long as she doesn't commit another crime in a certain period of time, she will never go to jail.  That's if she doesn't plea bargain it down. 

Personally, if I had been that negligent, I would like to think that I would plead guilty, throw myself on the mercy of the court, and hope for the best. 

One other side effect of having the criminal conviction that I do not necessarily think is a bad thing - it will severely limit her ability to have fabulous overseas vacation.  Most countries will not give you a visitor's visa easily if you have a felony conviction.  She'll still probably be able to travel because she's unlikely to be a risk to their populations, but it will make it a pain in the *** for her, and I'm ok with that.  (I love watching Border Security: Australia LOL)

15 hours ago, TNnursejane said:

Yes, Ms Vaught made a terrible error but the issue comes down to she missed all of the safety points that were put into place. My question is why did she override the med when if it was ordered should have been in the patient's profile. If she had given Versed in the past, she would have known if did not have to be reconstituted as was the Vercromium that she administered. My concern is that if she is convicted and sentenced then it will change the whole "just" culture that we have been working on since the early 2000s. Nurses will not report errors anymore because they are afraid of the repercussions. The bottom line is that it could have been any of us. It has to do with the processes that went wrong. I'm sure that Ms Vaught did not do this maliciously. She should suffer the consequences such as losing her license and/or paying a fine but to be put in jail is going over the top.

I believe in "just culture", but I also feel that it can be used to cover up negligence.  Just culture should not mean that the medical profession is exempt from the law.  I am not afraid to report my mistakes still - I work hard to not be negligent. If I make an error, I report it, try and get the systems fixed, because I'm trying to use the safety systems.  I don't want to bypass and override them at all.

If the doc had ordered vec by mistake, the pharmacist verified it and added it to the patient profile and she had administered it, it still would have been a horrific error, but it wouldn't have risen to the same level of negligence - the drug matched the order, it already got missed by several people, no overrides were done.  That is a systems issue, multiple people failing to notice an error, the swiss cheese effect with the nurse being at the end of the line. 

But that's not what happened at all.

11 hours ago, juan de la cruz said:

This case is not the only one ever involving a nurse who has committed a medical error that led to death and I'm sure if we dissect each one of those other cases, many will meet criteria for some version of involuntary manslaughter, reckless homicide, etc which I agree is classified as a crime. You also said so yourself in a previous post that many deaths occur in hospital every year due to medication errors.

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.

If Nurse RV's case is the tipping point toward criminal prosecution of medical errors resulting in death, we would be setting our legal system up for more cover up's, more facilities washing their hands off of cases where the culpability is not entirely attributable to a single healthcare professional but a whole system in general. That's what others are referring to as a slippery slope and we have to accept that there are nuances in many of these cases. It's never a black and white matter like you are insisting.

We can only strive to develop systems that could thwart them as a method to prevent these from happening. You are deluded if you think that prosecuting healthcare professional in criminal court will deter these incidents from happening and there's no way you will change my mind about that.

I honestly don't know if prosecution for criminal negligence is much of a deterrent in any situation for the first crime.  But I do think it is important to hold people accountable when they are negligent and harm people. That doesn't always have to mean jail time, but definitely will be a deterrent for that same person being negligent a second time, and if they show that same pattern of negligence and harming people, then they need to be in jail to protect the rest of society.

10 hours ago, Wuzzie said:

Too late. It’s happening in Ohio. So tell me, all those nurses who gave fatal doses of Fentanyl ordered by a particular doctor. Did they all make a “mistake”? 

I want to wait until I see all the information on those cases before I decide. We have the CMS report with a lot of facts for this case, but not a lot of facts, only media reports so far in the Columbus case.  I am from the area originally, so I'm definitely following it. 

2 hours ago, juan de la cruz said:

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.

I can't find the details on that case, but if it is similar with bypassing safety measures, they should have charged the nurse and taken the license. I don't like the excuse though that they weren't doing it for other people so we shouldn't ever do it.  I think we should all be accountable for our actions, doctors, nurses, NPs, PAs, RTs, lay people. 

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2 hours ago, student24 said:

I just did right before go to work. We need to prevent her from going to jail because this can be one of us in this complex profession that is in constant demands.

No it can't unless you're a complete idiot, don't know your medications, don't follow the 5 rights and override every single warning and safeguard in place to prevent these kind of disasters.

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