For the sake of every other patient in a hospital in this country, I hope CMS and the general public understand that she has not done any one single wrong here that hasn't been done innumerable times. I bet every one of them has happened at V in the past 8 hours.
- Failure to conscientiously read a label
- Fail to ensure 5Rs
- Use override function on pyxis
- Failure to monitor according to SoC
Many, many people have done #1 and/or #2. Usually when they do, we all say, "Don't be so hard on yourself!" Either that or no one ever even knows about it because it didn't lead to an actual mistake or if it did, there was no obvious patient harm
If you've been a nurse since before auto-profiling, especially in certain departments, there's a good chance that #3, using "override," is (or fairly recently has been) SoP in your work area.
That aspect of this makes me particularly sick because the entity in question is using the override thing to make this look particularly evil. And actually the override wasn't the major problem here.
But if you don't claim it was the (utterly reckless) major problem, then eventually you might come around to some of the other factors, like the idea of a newer nurse who clearly was not prepared enough for this role to be familiar with either of these two medications or the required monitoring, being in a role of roving help-all while orienting someone even newer while being sent all over the damn hospital (or to at least two different outpatient departments, in one of which there were no other clinical/nursing staff present and no tools for nursing care), to do these various things, neither of which were urgent or even necessary, so that she could medicate the patient of a nurse who couldn't medicate her own patient because she was busy watching two full assignments' worth of patients in the ICU.
You might not think so, but you've probably done #4, too. If you've missed a set of important vitals, if you haven't reassessed as quickly as you should after giving pain medication, if someone took your patient off the monitor and didn't put them back on, if you delegated a monitoring-related task that was then not completed in a timely manner (vitals, blood sugars, etc., etc., etc.)
The most unfortunate and egregious thing was not reading the label, and that's the bottom line.
But what she did NOT do was "bypass a hospital safety measure *in order to* gain access to the lethal drug used to to execute inmates on death row."
Oh, and she is also charged with impaired adult abuse. Which I'm guessing, to avoid "inadvertently" sounding like something isn't, would have been better written, "impaired-adult abuse" (IOW, the patient was impaired secondary to the medication).