Radonda Vaught Trial

[tnbutterfly - Mary]

"Fourteen Nashvillians were chosen Monday, March 21, 2022 to sit as a jury in the case of RaDonda Vaught, a former Vanderbilt University Medical Center nurse charged in the death of a patient. She faces charges of reckless homicide and impaired adult abuse in the 2017 death of Charlene Murphey."

For more on this story, see

Jury chosen in homicide trial of ex-Vanderbilt nurse RaDonda Vaught after fatal drug error

RaDonda Vaught’s Arraignment - Guilty or Not of Reckless Homicide and Patient Abuse?

Tennessee Nurse RaDonda Vaught - Legal Perspectives of Fatal Medication Error

What do you think the verdict should/will be?

[MaxAttack, BSN, RN]

On 3/31/2022 at 6:29 PM, MunoRN said:

Their point is if you support criminalizing errors, keep in mind the precedent of these charges aren't limited to as severe of cases as this, then you don't really support systemic safety measures and having multi-tiered patient safety, it can't be both.

This is a great example of a false dichotomy and it truly makes no sense. This is like saying if you support criminal charges against murders then you don't support gun control.

In RaDonda's case, I understand a criminal conviction (not that I necessarily agree or disagree with it) while at the same time see the need for a systemic analysis to identify actions that can minimize the chance of it happening again (e.g., putting scanners in imaging areas).

[JBMmom, MSN, NP]

10 hours ago, Wuzzie said:

Maybe we should just slap on a bar code and hope for the best. ?‍♀️

Kind of like when I buy the cans without a label off the scratch and dent shelf because they're insanely cheap. Could be refried beans, could be peaches, who knows? If we're not going to pay attention it all becomes a crap shoot. 

[Julius Seizure]

9 minutes ago, JBMmom said:

Kind of like when I buy the cans without a label off the scratch and dent shelf because they're insanely cheap. Could be refried beans, could be peaches, who knows? If we're not going to pay attention it all becomes a crap shoot. 

It makes mealtime more exciting at least.

[HiddenAngels]

On 4/3/2022 at 11:00 PM, Susie2310 said:

Even if a nurse failed to read the medication label for whatever reason, checking the Five Rights the multiple times we are trained to do this would have caught this:   First check: When receiving/reviewing the order; 2nd check:  When obtaining the medication and preparing the medication; 3rd check:  When taking the medication in to the patient to administer it; 4th check:  After you've administered the medication.  The Five Rights is a physical process that utilizes critical thinking.  It's a process that has been drummed into nurses since nursing school.  To miss all of those checks (and others), in my view, is to have missed everything about administering a medication safely.  To say that someone could miss all those checks and have no idea that they had made a mistake is like saying that as an airliner is preparing for takeoff the people in charge of flying the plane either forget to do all the pre-take off checks, are distracted to the point that they don't do the pre-take off checks, or don't bother to do them.  Whichever way you look at it, the person/s who are responsible for the aircraft and for flying the plane safely are negligent.  No nurse or airline pilot "forgets" to do critical safety checks that have been drummed into them since the beginning of their training; they omit to do the checks because they make bad, irresponsible, choices.

Great Analogy

[MunoRN, RN]

On 4/6/2022 at 2:57 PM, MaxAttack said:

This is a great example of a false dichotomy and it truly makes no sense. This is like saying if you support criminal charges against murders then you don't support gun control.

In RaDonda's case, I understand a criminal conviction (not that I necessarily agree or disagree with it) while at the same time see the need for a systemic analysis to identify actions that can minimize the chance of it happening again (e.g., putting scanners in imaging areas).

I feel like I've explained that position in detail a few times, including examples and references to patient safety organizations, and I would agree that your example makes no sense.  It might help if you could explain why you think that's a similar argument to current patient safety paradigms.

Again, the patient safety systems that have evolved over the past decade or more rely on nurses reporting errors and near misses in order to implement measures to prevent that in the future.  And that's separate from the importance of having nurses report recognized errors immediately following an error to limit imminent harm to the patient.

I think people mistakenly assume that the way the law works is that this only sets a precedent that it's a criminal act to mistakenly have vecuronium in your hand or give it to a patient, it's the same crime if we're talking about famotidine.  If we can't respond to contributors of benign, and fairly common medication errors then that also limits our ability to prevent ones like this.  

Again, I'm interested in, and open to why that's not the case.

[Susie2310]

 

3 hours ago, MunoRN said:

 

Again, the patient safety systems that have evolved over the past decade or more rely on nurses reporting errors and near misses in order to implement measures to prevent that in the future.  And that's separate from the importance of having nurses report recognized errors immediately following an error to limit imminent harm to the patient.

I think people mistakenly assume that the way the law works is that this only sets a precedent that it's a criminal act to mistakenly have vecuronium in your hand or give it to a patient, it's the same crime if we're talking about famotidine.  If we can't respond to contributors of benign, and fairly common medication errors then that also limits our ability to prevent ones like this.  

 

We know that errors/lack of judgment in care that result in harm to patients are not uncommon (let alone near misses), and my understanding is that the great majority of these are estimated not to be reported.  While Just Culture and methods that facilitate and encourage reporting are of value, in my view this seems to be a strategic moment where new patient safety studies should be done with the goal of finding new methods/innovations to prevent both errors/lack of judgment in care that result in harm to patients and to  identify errors and lack of judgment in care promptly in real time in order to promptly take appropriate patient interventions to mitigate the harm of these errors/lack of judgment in care, and to reduce reliance on voluntary systems of reporting by health care professionals.    

I think that new external oversight of facilities in regard to patient safety could be beneficial for patients and that much can be done moving forward in regard to patient safety if there is the industry will.

In regard to your second paragraph above, I can't see that errors/misjudgments in care that involve medications with a generally low potential for harm would be treated exactly the same as those involving medications that are known to have a high risk of injury/harm to the patient and I disagree with your statement about a precedent being set.

 

[Mommavik, ADN]

---

In response to Susie 2310; 

(Sorry I can't figure out how to copy the post)   I agree; this is way more than just a medication error, like we are all afraid we could one day make. This was more than 8 times this error could have been caught BEFORE the med was given. Over 4 were before the med was even taken from the machine!  I'm sorry, but even with distractions, I can't understand how she could not have seen the name of  "Vecuronium"  or the word  " paralytic" at some point while reconstituting this med. It was on the label,  it was even on the vial cap so it HAD to be seen when the needle was inserted into the vial to reconstitute the med and when it was inserted to withdraw the med from the vial. Several other points of this incident that stand out as agregious. The hospital, the doctors, the other nurse also held some blame, but there were so many things that could have been done to prevent this. (And I'm aware hindsight is always perfect,) This could so easily been prevented that it just makes me cringe for the patient, her family and yes for Radonda herself. This will eat at her forever as I know it already it.  I hope she does not get jail time,  because I think what she already has had happen is harsh enough. The publicity alone will ensure she never is allowed to live her life without constant reminders of this.  The other point is that this trial doesn't cause a precedent that  reporting a med error increasing your chance of being charged with a crime.  We still need the checks and balances system of self reporting so that we can help find out why errors happen and how we can prevent them from happening again. We CANNOT let this system be corrupted to cause prosecution for an accidental error. (We all know this was not that)

[Hoosier_RN, MSN]

1 hour ago, Mommavik said:

---

In response to Susie 2310; 

(Sorry I can't figure out how to copy the post)  

Select "quote" at the bottom of the box of the post that you want to quote. You can edit out any words that you wish

Ole!

[Mommavik, ADN]

Thank you!

[Emergent, RN]

There have been criminal prosecutions in other professions when someone's negligence causes death or destruction. I googled this one and thought it had some similarities. The pilot wasn't accused of being inebriated, but blew past several safety rules. If you read the rest of the article he says that the electronics were failing. I don't know the outcome of this, but I thought it was a worthy comparison to a nurse who ignored the standard of care and had a disastrous outcome.

Should people ever be prosecuted when their errors due to negligence cause great harm? Why should a nurse be exempt?

Ship's Pilot Charged

Quote

The “criminal information” filed in U.S. District Court in San Francisco accuses Cota of failing to safely guide the container ship safely through the bay. Specifically, the government says Cota failed to use the ship’s radar as he approached the Bay Bridge; failed to adequately review the proposed course with the captain; and failed to use navigational aids that might have helped him avoid disaster.

“These failures led to the Cosco Busan striking the bridge and spilling the oil,” the Justice Department said in a statement.

 

[HiddenAngels]

Interesting. It says he might have taken something that impaired  his judgment. I’m curious now, I wonder if this was RV 3rd 12 in a row or something 

[mtmkjr, BSN]

35 minutes ago, HiddenAngels said:

Interesting. It says he might have taken something that impaired  his judgment. I’m curious now, I wonder if this was RV 3rd 12 in a row or something 

I believe it was her second and when asked if she was fatigued, she said no