Jump to content
2019 Nursing Salary Survey Read more... ×
Nurse Beth Nurse Beth, MSN (Advice Column) Writer Innovator Expert Nurse Verified

Nurses Call the Governor of Tennessee

Nurses   (12,467 Views 422 Comments)
273 Likes; 10 Followers; 79 Articles; 224,078 Visitors; 1,651 Posts
If you find this topic helpful leave a comment.
advertisement

You are reading page 5 of Nurses Call the Governor of Tennessee. If you want to start from the beginning Go to First Page.

On ‎2‎/‎9‎/‎2019 at 8:13 AM, Nurse Beth said:

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: bill.lee@state.tn.us

District Attorney Glenn Funk

Beth,

I respect you. I really do, and I will agree to disagree on this subject with you, any day---

however.

Be very careful what you wish for and advocate. The nurses and anybody else who is a professional who agree that she should be charged and judged by a jury of her peers can also call the Governor's office.

Just a thought.

Share this post


Link to post
Share on other sites

I'm sorry, I cannot support this measure.

This was not a simple mistake this nurse made.  She willfully bypassed not one, not two, but MULTIPLE steps of safety that directly caused the death of this patient.  

Any ONE mistake is forgivable, not as many as she did.

I would encourage anyone that is considering supporting the Vanderbilt nurse to read the CMS report directly.  It is long, but you can skim through it quickly.  

There has to be a limit folks, on how far you can take negligence before it becomes criminal.  We are state licensed, college-educated professionals.  We need to act like it.

I don't support protecting physicians that are reckless and I am not going to support a nurse just because I am one.

To those that think, "Oh, this can happen to any of us.".  I work with a pharmacist that killed a patient. He still has his license, he still has his job, there is NO PUBLIC RECORD of what he did....want to know why?  Because it was a simple mistake anyone can do....he added a medication twice to an IV bag and had a complete memory lapse because they were short handed that he had already dosed the bag.  

It was ONE mistake. The end result doesn't matter.  

You can rest assured this nurse has done this before with other meds...it just happened to kill someone this time.  The statistics caught up with her.  A new grad nurse would not have made the same mistake.

If you are going to support this nurse, I am sorry....but exactly what type of negligence are you going to be OK with accepting in our profession?  How far does it go? Is there any limit at all?

Edited by Jory

Share this post


Link to post
Share on other sites
14 hours ago, mtnNurse. said:

Wuzzie, we all see how badly you want to see this nurse be charged guilty as a criminal. Would you be willing to elaborate on what would be enough for you to feel justice was served? How many years in prison alongside willful murderers should she serve in your opinion?

Have you even read the CMS report?  Not read the news stories, have you actually pulled it up?

If you think this nurse made only ONE mistake....she didn't.  That is why she is being charged with reckless homicide.  She made MULTIPLE mistakes . 

1.  She didn't wait for the physician's order to load and for pharmacy to verify the order.  CHECKPOINT #1 bypassed . 

2.  She went to find Versed in the Pyxis and didn't find the medication, so she tried to enter the name and found a completely different drug....whose name WASN'T EVEN CLOSE to Versed.  So she pulled vecuronium instead. CHECKPOINT #2 bypassed.

3.  The Pyxis, according to the CMS report, had a warning in red stating this drug should only be used with a stat order. The nurse did not have a stat order.  CHECKPOINT #3 bypassed.

4.  She didn't look at the vial to see if it was versed versus vecuronium, this was by her own admission. CHECKPOINT #4 bypassed.  

She did check the patient's name to make sure that was correct.  

5.  Had she looked at the vial at all, she would have seen the vecuronium had been marked with red packaging identifying it as a paralytic.  Checkpoint #5 bypassed.

6.  She was obviously not familiar enough with versed to know that versed does not need to be reconstituted.  Vecuronium does.  If you are not familiar with the administration of a drug you need to look it up or check with pharmacy.  Had she done this her error would have been caught.  Checkpoint #6 bypassed.  

7.  Even though the drug had been pulled on override, she still could have scanned the medication to make sure it was the one the physician ordered before she administered it.  This would have identified the medication as being incorrect.  She didn't.  Checkpoint #7 bypassed.  

She didn't monitor the patient after administration which isn't really a system bypass, it's just a nurse that didn't give a rat's behind if the patient had a reaction or not...she was moving on.  

She had SEVEN occasions to save this person's life. EIGHT if you count the fact she should have monitored the patient after administration.

So...it is important to know the list I have provided is why the nurse is being charged . She didn't make ONE MISTAKE.  Nurses make mistakes that result in patient harm/no harm all the time.  They are not all reported to the BON and we don't see rogue DA's charging nurses with reckless homicide.  

But this is to put all nurses on notice....if you are not going to be bothered with following procedures, you are going to be held accountable if a patient is harmed and losing your license is going to be the least of your worries.  

I have about as much sympathy for this nurse as I do a drunk driver.

***By the way, if you are wondering why she is being charged with reckless homicide, it's because she did not intend to kill the patient.  It is an appropriate charge.  The patient died at the hands of another human.  That is homicide. She was reckless in her actions.  Intent is not part of the legal criteria***

Edited by Jory

Share this post


Link to post
Share on other sites
9 hours ago, 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

In one study of inattentional blindness, 5 radiologists viewed a chest Xray with a missing clavicle. Not one identified the missing clavicle.

Then there's the famous gorilla in the background You Tube.

We see what we expect to see- confirmation bias.

 

Share this post


Link to post
Share on other sites

Here's a synopsis of the Denver case mentioned by @juan de la cruz 

In October 1996, a medication error at a Denver-area hospital resulted in the tragic death of a newborn infant. The error involved intravenous administration of a large dose of penicilin G benzathine. Penicillin G benzathine is insoluble and must never be injected intravenously. Many who learned about the incident were quick to focus blame for the death solely on the nurses--because nurses are responsible for knowing about the potential dangers of drugs they administer.

The District Attorney of Adams County, Colorado, brought the case before a grand jury. The three nurses involved in the infant's care were eventually indicted for criminally negligent homicide. In preparation for the trial that followed, a systems analysis was performed by the authors on behalf of the defense team. The analysis revealed over 50 latent failures in the system that contributed to the tragedy, allowing the accident to occur.

After being presented with the evidence during the trial, the jury delivered a 'not guilty' verdict. Through their verdict, the jury also sent an important message to health care providers:

We must look beyond blame and focus on the multiple, underlying system failures that shape individual behavior and create the conditions under which medication errors occur.

Share this post


Link to post
Share on other sites
5 hours ago, HomeBound said:

Beth,

I respect you. I really do, and I will agree to disagree on this subject with you, any day---

however.

Be very careful what you wish for and advocate. The nurses and anybody else who is a professional who agree that she should be charged and judged by a jury of her peers can also call the Governor's office.

Just a thought.

Thanks, HomeBound, I respect you, too. I agree with you, that's why I chose the words "to let him know what you think about this choice" 

Share this post


Link to post
Share on other sites
advertisement
26 minutes ago, Nurse Beth said:

Here's a synopsis of the Denver case mentioned by @juan de la cruz 

In October 1996, a medication error at a Denver-area hospital resulted in the tragic death of a newborn infant. The error involved intravenous administration of a large dose of penicilin G benzathine. Penicillin G benzathine is insoluble and must never be injected intravenously. Many who learned about the incident were quick to focus blame for the death solely on the nurses--because nurses are responsible for knowing about the potential dangers of drugs they administer.

The District Attorney of Adams County, Colorado, brought the case before a grand jury. The three nurses involved in the infant's care were eventually indicted for criminally negligent homicide. In preparation for the trial that followed, a systems analysis was performed by the authors on behalf of the defense team. The analysis revealed over 50 latent failures in the system that contributed to the tragedy, allowing the accident to occur.

After being presented with the evidence during the trial, the jury delivered a 'not guilty' verdict. Through their verdict, the jury also sent an important message to health care providers:

We must look beyond blame and focus on the multiple, underlying system failures that shape individual behavior and create the conditions under which medication errors occur.

http://www.wmcactionnews5.com/story/23147169/nurse-indicted-after-negligent-death-of-3-year-old-girl/

 

And here's one where a nurse bypassed a safety mechanism (turned down the alarm on a pulse ox) and got distracted doing something else. I see a parallel. Do you think she should have be re-educated?

Edited by Wuzzie

Share this post


Link to post
Share on other sites
12 hours ago, Nurse Beth said:

Whereas nurses are expected to mange call lights, push meds, answer their phones, and so on. As if they are not making critical decisions.

1

We are taught/expected to prioritize tasks.  If I'm giving a med that requires my patient to be monitored, I'm going to let call lights and phone calls go for the time being until I know that the more critical task has been fully attended to.

Share this post


Link to post
Share on other sites

I think the middle ground is best. Radonda should have her license revoked in my opinion.  She has proven that she is incompetent. 

I think criminal charges will accomplish nothing. Let her train for a different occupation. Many people survive in life without a nursing license. 

Share this post


Link to post
Share on other sites
14 hours ago, BarrelOfMonkeys said:

I’m actually hoping this goes to court and changes how we do things. Setting new precedent for maybe better patient ratios in healthcare which can reduce nurse mistakes/errors/misjudgements (whatever you choose to call it) due to poor working conditions and in turn promote healthier outcomes. It’s sad this has happened but I’m all for hoping this awful reality is the thing that helps the system change. 

I think the reality of her going to court is that she will be punished and the legal system will say "well, took care of that," and be done with it. I fail to see how that will put any pressure on facilities to improve working conditions if the only person held to account is the nurse. 

Share this post


Link to post
Share on other sites
12 hours ago, JadedCPN said:

I completely agree. I would be curious if the same people who do not think she should be criminally charged (charged, not automatically found guilty) would feel the same way if it were a similar scenario in a field they weren’t directly involved in and thus not as passionate about. Not sure if everyone would be calling for it to just be handled internally if it were an airline pilot, truck driver, cab driver, etc. But I absolutely could be wrong.

This bears repeating: when pilots who survive make errors (and the majority of negative events in aviation are due to pilot error), unless they are chemically impaired, they rarely to never get charged criminally.

Edited by Horseshoe

Share this post


Link to post
Share on other sites
5 hours ago, Jory said:

***By the way, if you are wondering why she is being charged with reckless homicide, it's because she did not intend to kill the patient.  It is an appropriate charge.  The patient died at the hands of another human.  That is homicide. She was reckless in her actions.  Intent is not part of the legal criteria***

Jory, I'm going to get to your other points in another post, but for you to write this -- well, you obviously haven't read my posts in which I talked about all of that. Whether it's an appropriate charge is up for debate (laws are open for interpretation) and I have been debating it and wishing you'd go back and read my good points about "reckless homicide" and how it does not apply to her, at least not from anything about the case or about her that we have knowledge of so far. If you're curious why I think this, please go read all posts on the other threads. I suspect you aren't curious why I think this or why anyone would want to defend her and it seems like it upsets you that we aren't getting it over with and locking her up in prison this very minute, because of what you say here:

5 hours ago, Jory said:

I have about as much sympathy for this nurse as I do a drunk driver.

A nurse's job and how we have to buck the system in order to prioritize patient safety over fulfilling the impossible demands of the administration does not compare to a drunk driver!!!

Share this post


Link to post
Share on other sites
×