This is something I have been following on the side but have not seen many people talk about, and I was wondering what you all thought about it:
RaDonda Vaught, a former nurse criminally prosecuted for a fatal drug error in 2017, was convicted of gross neglect of an impaired adult and negligent homicide on Friday after a three-day trial in Nashville, Tenn., that gripped nurses across the country.
Vaught faces three to six years in prison for neglect and one to two years for negligent homicide as a defendant with no prior convictions, according to sentencing guidelines provided by the Nashville district attorney’s office. Vaught is scheduled to be sentenced May 13, and her sentences are likely to run concurrently, said the district attorney’s spokesperson, Steve Hayslip.
Vaught was acquitted of reckless homicide. Criminally negligent homicide was a lesser charge included under reckless homicide.
Vaught’s trial has been closely watched by nurses and medical professionals across the U.S., many of whom worry it could set a precedent of criminalizing medical mistakes. Medical errors are generally handled by professional licensing boards or civil courts, and criminal prosecutions like Vaught’s case are exceedingly rare.
Janie Harvey Garner, the founder of Show Me Your Stethoscope, a nursing group on Facebook with more than 600,000 members, worries the conviction will have a chilling effect on nurses disclosing their own errors or near errors, which could have a detrimental effect on the quality of patient care.
My gut instinct is that she should not be on trial, but the Vanderbilt UMC should for cutting corners and not having actual pharmacists, but again, I am not an expert in this and that is just my initial reaction. What do you all think?
Baud
The allegations
Alison Rose ???
Dang, that’s a tough one, and I’m glad it’s not up to me to decide what happens to someone like this. On the one hand, she’s not a pharmacist but she is a nurse, and the fact that the two drugs come in totally different forms ought to have been something she noticed right away. But then…unless there’s some crazy plot twist coming, this wasn’t intentional and it doesn’t seem like she’s going to run around killing people. But then again…someone is dead who shouldn’t be because of her mistake.
Oy. I don’t know.
Suzanne
I don’t know if there’s any evidence of that. The medication cabinets they’re talking about (Pyxis, Omnicell, or similar) are usually stocked by a pharmacy employee but are stored on the patient units, usually within a controlled Medication Room (which has cameras). This is how it is in the vast majority of hospitals and care centers. Nurses access the cabinets to fetch the meds.
There are supposed to be protocols in hospitals to make sure nurses aren’t distracted when getting the meds out, that they take them to the correct patient, etc. Like anything else, everyone gets lackadaisical when they’re in a hurry or overworked. And that was every nurse, even before the pandemic.
piratedan
1) that’s a pretty egregious error… wrong drug name, wrong substance type, plus blowing thru the system warning messages
2) without diving into the case specifics (because I am at work), training and work environment matter… if this took place during the time of COVID or even if there were too few nurses and too many patients it can happen where you fall into a mindset of just following a routine or an internal protocol and operate in a mind fog environment. Don’t want to give the impression where I condone this error, but people are human and what clinical staff get subjected to during these last few years makes me very leery of playing the blame game.
Anonymous At Work
Worth checking since I don’t know about it. Typically, there’s a nurse between the patient and the pharmacist. How it is delivered to the nurse can vary but there should be a protocol. Vanderbilt UMC almost certainly had one (too good not to). The question becomes: was the nurse properly trained and kept trained, properly staffed so that she wasn’t too tired or overworked, or any other systemic breakdown other than making a huge error by acting against protocol?
trollhattan
California purportedly regulates the senior care industry and yet it takes egregious problems before they seem to stir into action. So yeah, I can believe it’s even worse elsewhere.
Getting “good help” requires paying the staff well and that seems not to be the case. Just for starters.
Betty Cracker
It’s tragic, and from Baud’s description at #1, it sounds negligent. But can understand nurses’ and other medical professionals’ concern about criminalizing medical errors. People make mistakes. Usually the consequences aren’t a matter of life and death, but in that job, they can be. We want people to take on tough but necessary jobs, so criminalizing mistakes seems like a bad idea.
Cervantes
This is a terrible mistake. To criminally prosecute a health care provider for making an error discourages disclosure and honest investigation. Improving quality and preventing errors requires encouraging people to come forward and honestly report mistakes, and cooperate with investigations. It also requires designing systems so that human error is less likely to occur, or to have dangerous consequences when it does. In this particular case, the nurse does appear to have been unacceptably negligent, but the hospital can fire her and the family can sue her and the hospital, which I assume is happening anyway. Criminal prosecution is totally counterproductive.
An intentional act is obviously a different matter altogether.
It is a fact that when nurses or physicians make mistakes, the consequences can be much graver than mistakes by people in most occupations. At the same time, the tasks are more complex and offer more opportunities for error. If the threat of criminal prosecution attaches to mistakes, ,few people will want to do those jobs.
FYI, I am associate professor of health services, policy and practice at the Brown University School of Public Health.
CaseyL
I’ve seen a few comments on Twitter about this; thanks for giving the background information. I’d normally be inclined to cut the nurse some slack, but it seems that she ignored multiple warning signs. Since it’s unlikely she meant to kill anyone, “negligent homicide” seems a reasonable charge. As a nurse, she has a duty of care to pay attention to what she’s doing.
@piratedan: If I read the story correctly, she killed the patient in 2017 – long before the pandemic.
VeniceRiley
In ‘Merica, if you have a penis and are white, you can DUI kill a man with your car and continue being an Attorney general of an entire state.
brendancalling
I’d brace for a exodus from the field. No one is gonna want to be a nurse—the hours suck, the work is hard and traumatizing, raises are few and far between, patient and patients families regularly treat them like shit, and administration also treats them like shit. Now they have to worry about going to jail for doing their jobs?
you’ll see a lot of people leave.
Chief Oshkosh
The article may not be informing the reader adequately; one hopes that the jury was better informed. For instance, several warning signs were noted in the article to have been ignored. Just one example of that is given, that the two drugs are in different storage formulations. That’s not necessarily much of a warning sign. Once you’ve grabbed the drug, you just follow the instructions on the kit/bottle/box for prepping and delivering. In the end, both are injected, it’s just that the wrong drug needed extra prep steps, presumably for freshness. Possibly there were other warning signs that were ignored, but this single one is not highly damaging, imo.
Suzanne
@Anonymous At Work: I read into this a little more. It appears that nurses had to override the warnings on the meds cabinets frequently to access them. Apparently all the nurses have to do it all the time, and she probably stopped reading them. Just like most of us when we get error messages on our computers. There’s a similar problem in hospitals with nuisance alarms…. everything beeps so much that it all just blends together and people tune it out.
jonas
From the looks of it, it was not intentional, but egregiously negligent. Didn’t the doctor who gave Michael Jackson a fatal dose of propofol get just a couple years in prison for that? And he knew perfectly well what he was dispensing.
Old School
I think of it similar to the Kim Potter case – the officer who drew her handgun instead of her Taser. I can believe the result wasn’t intended, but that doesn’t help the deceased.
patrick II
The last time drugs were administered to me in a hospital the nurse read the names off and asked me if I was taking that medicine. Is that usual?
Ken
@VeniceRiley: @Old School: Maybe the solution is to give healthcare workers qualified immunity.
The Moar You Know
America loves to jail people unless they are powerful/important/rich. She should not be in jail. Fired? Yeah. Lose her license? Possibly. But jail? I’m not seeing it
ETA: quite a bit was made at the trial about her ignoring warnings from the machine. From what I understand, every nurse using that machine routinely had to blow through warnings many times a day. People stop reading them. I’ve been an IT admin for close on 20 years now and that’s a problem engineers caused; too many warnings and people just stop reading them. God knows my users don’t. Should they be jailed?
Hmmm. Can I have my users put in jail for ignoring obvious stuff? Sooooo tempting…
Suzanne
@patrick II: YES, that’s a common protocol if a patient is capable of answering. There’s supposed to be multiple checks throughout the process of providing meds.
The detail that I read about this case that I find most concerning is that she apparently gave the drug and then no one checked on the patient for 25 minutes.
Barbara
@Suzanne: This is a huge issue for warning systems of all kinds, but especially electronic prescribing systems medication warnings. These systems can generate so many errors, most of which are not actually considered to be noteworthy, that many professionals stop paying attention. It’s still hard for me to see how you could defend someone by arguing that the general uselessness of most of the error reports made it reasonable to ignore all of them, which is what she did — in addition to overlooking other things that she should have been aware of such as the form of the drug and so on.
Recently, my husband opened a prescription package to find that it contained the wrong medication. Since he had been taking the drug for years he knew immediately it was wrong, and the name on the bottle (prepackaged, not counted out and put in an amber container) was also wrong when he checked. I took it back to the pharmacy and they said that what happened is that the bottles for the two drugs look so much alike that someone pulled the wrong one off the shelf without checking. They were aghast, and had to file a report.
So yes, these things happen, and it’s just luck that most errors don’t seriously injure or kill someone, but you can’t overlook them generally. As to whether she deserved criminal culpability, I don’t know, but any kind of “accident” that results in serious damage is almost certain to incur greater liability
@The Moar You Know: There is no question that failing to designate “red” or “orange” or “yellow” categories of error can make these systems basically useless. Other mechanisms would be to require the person to affirmatively check that they intend to administer a specific product (e.g., one that is unusual or especially consequential) OR even better, to require that there be an order in the system for that patient for that drug, with the only exceptions being for emergency or stat situations.
Mike Field
My background is in communications at a major university with an academic health center and having helped done a fair amount of work on the issue of medical errors. Ever since the 2000 publication of ‘To Err is Human’ there has been growing awareness of the scale and cost of medical mistakes. A Johns Hopkins study published in 2016 in The BMJ posited that medical errors kill 250,000 in the US each year making it the 3rd leading cause of death. A large percentage of medical errors, we argued (and I believe) are system design flaws — in other words, a doctor or nurse who is able to retrieve and administer the wrong drug is working in a flawed system that should in fact make it nearly impossible to do so. From that perspective, it is morally and ethically a profoundly different medical error than a surgeon who shows up to the operating room blind drunk. So I share the sense of unease — to say the least — in so far as my knowledge of the case in only how the story is presented here. — Mike
Suzanne
@The Moar You Know: We are required in most jurisdictions to design enclosed rooms with vision windows and access control on the doors for medication storage and preparation. There’s lighting standards, as well. All of that is to reduce distraction and noise, increase clarity, and to encourage peer surveillance. But none of that really helps the “click through 5 alert messages that show up all the time to the point that they become meaningless” issue.
Cameron
I don’t know enough to have an opinion on the right call for this case, but one thing I’m sure of is that the anti-vax families of anti-vaxxers who died of COVID while under medical care will see this as the green light to attack medical providers for failing their loved ones. They’re already doing it just to avoid responsibility; now they can claim NEGLIGENCE!
Suzanne
@Barbara:
I’m certainly not defending her here. But it’s a crappy system. Apparently the nurses were literally instructed to override some of the warnings at times.
Barbara
@Cervantes: I don’t know if I would go quite that far because the consequences were so grave and the warnings were so clear and dire.
Felanius Kootea
Unfortunately, alert fatigue is a well-documented thing when it comes to health care providers using computerized systems in clinical practice. Too many warning signals that are not critical can lead to someone overlooking an actually critical warning because it all becomes noise.
She was distracted and made a terrible mistake. I think she should have faced civil liabilities but not a criminal charge. This wasn’t intentional.
Roger Moore
@The Moar You Know:
If ignoring the error messages kills someone, maybe they should go to prison for ignoring them.
Barbara
@Suzanne: Yes, indeed, this has been an issue for a long time. There are “errors” (driving 40 in a 35 MPH zone) and there are ERRORS (going 40 MPH as you pull around a stopped school bus). You can’t ignore every warning sign out there just because they are common. Somehow you have to learn to distinguish between them, even if your systems don’t give you the best tools.
pacem appellant
It was a grave error and lead to death. True. And it’s true that Nurse Twitter is correct: Vaught should not have been tried, much less convicted for homicide. There are too many whatabouts running about that muddy the discussion, IMO (There are plenty of egregious examples of the criminal justice system getting it wrong in the opposite direction). Regardless, this is not a case of criminal homicide.
MFA
“…the Vanderbilt UMC should [be prosecuted] for cutting corners and not having actual pharmacists…”
This is my thought. The system VUMC used was clearly poorly designed, and yes, the intent of every such system is sold to an administration as a theft-prevention, risk reduction, and cost cutting measure — the expensive pharmacist(s) are no longer spending time dispensing, and won’t take the blame if something’s done wrong–instead, there are fewer of them and they’re mostly just authorizing orders; so their expertise in drug use and formulation falls by the wayside. Instead, the machine pulls and dispenses to the nurse. The drug selection system is alphabetical by name; so if a nurse types “V-E…” is prompted to select from a list where V-E-C-… comes before V-E-R… and per the other commenter upthread, they just select from what’s offered and, out of habit, override the warnings. As if the nurse asked the pharmacist for the wrong thing and he just shrugged and provided it. But neither the Administration nor the system vendor will suffer for their choices.
So this person is being convicted, in essence, for a typo that the computer suggested.
Roger Moore
@Barbara:
There’s an additional problem with medicine because there are times where speed is of the essence. If someone is going into cardiac arrest, they need medication ASAP, not 5 minutes from now after you’ve followed every step in a long checklist. OTOH, that’s why they have crash carts. All the stuff needed to treat someone in cardiac arrest is in one place with no extraneous stuff that might cause confusion. If you see the big syringe intended to inject directly into someone’s heart on the crash cart, you don’t need to go through a long checklist to know it’s adrenaline.
Jay C
Yes, this is definitely a tough case: One the one hand, the sentence(s) handed out do seem, on their face, to be rather harsh, and seem to class Nurse Vaught as some kind of depraved killer: OTOH, there was most definitely serious negligence here: and in medicine, seemingly “minor” errors can have serious (if not always fatal, as in this case) outcomes.
@patrick II:
Yes, while I, thankfully, haven’t had the personal experience of it, Mrs. Jay has been (unfortunately) in the hospital several times recently, and yes: “nurses” in general, do often check with the patient to make sure they are dispensing the right medication. Which, as we see, is a fairly good practice.
Alison Rose ???
OT – Susan Collins had her concerns alleviated and her brow unfurrowed and shall now support Judge Jackson
Barbara
@MFA: Theft reduction is certainly one aim of these systems. However, so is getting the drug to the patient without waiting long periods of time for pharmacy to dispense the medication. Both of these drugs are used in preparation for surgery, but one is used for general anesthesia and the other is not. I wonder why they were stored in the same cabinet at all.
James E Powell
How does it compare with other deaths caused by negligence?
An auto accident. An auto accident w/DUI. Stampeding crowds at concerts. Negligently caused fires.
Police shooting unarmed person that appeared to be armed.
ETA – The Statement of the American Nurses Association & Tennessee Nurses Association
Mike Molloy
@piratedan: My thoughts exactly. What kind of overwork-related stress was this nurse operating under?
Barbara
@MFA: The lack of a pharmacist isn’t really an issue here because these drugs are not conventionally dispensed by pharmacists — you don’t actually know how much you might need to sedate a person undergoing anesthesia. These are drugs that are administered by people who are supposed to know what they are doing.
waysel
Interesting and informative article I stumbled upon: https://www.pharmacypracticenews.com/Clinical/Article/01-19/Another-Fatal-Vecuronium-Error-/53755?enl=true&sub=F09D4E1AEB1935236B7DD88EBF3511796624DD9967A417E04A63FAD9FB86. And yes,I’ve forgotten how to add links.
MaryLou
@Cervantes: Thanks for a balanced informed answer. After reading your comment, I agree 100% with your take on the situation. Anything that adds incentives to cover up mistakes, particularly in a medical setting, has to be bad in the long term. There are civil remedies available for the patient’s family to get just redress for the error.
ian
I am no lawyer, and don’t have a lot of firm opinions about this, but from the article
Seems like it would not fly if the issue at hand was accidental poison in your food or accidental damage in an automobile leading to death by car crash.
Benw
From the couple things I’ve read, this prosecution has enough red flags to be a CCCP rally. She had already faced all the usual punishments in the field for the egregious mistake, why was this even on the cops’ radar? Seems fishy
waysel
I was very disturbed by the idea a nurse might mix up Versed with Vecuronium based on the radical difference in spelling of each.
delk
They frequently overrode the system because they typed in brand names and the system wanted generic names.
Anonymous At Work
@Suzanne: Sounds exactly like a problem at a university hospital at which I worked that tried to roll out a content filter for internet access. Obgyn department says what now??? Yeah, I do system design in some weird ways now and have to pay attention to such things.
trollhattan
@Alison Rose ???:
Woot! Must be discing season for those furrows to have been leveled out. Thanks, Susan, I guess.
Ruckus
@patrick II:
Is that usual?
It depends on the hospital. And the situation. If you were in the ER bleeding out and/or unconscious, you might not be asked.
But in normal medicine one should be. I am very sensitive to many medications. I’ve been prescribed medications that cause unstable reactions in me but not others and been told by doctors that I have to take them anyway. Now I fend for myself and have told docs to fuck off when told I have to take something that makes my life untenable. They do not seem to like my response to their superior knowledge of my life and my continued breathing. Fuck them.
But. When someone makes a serious medication error there is something wrong. And often the person receiving the medication isn’t in a position to complain at all. The person dispensing, the system, or both may be the problem. In many cases it is that there isn’t enough overview but the reverse is also a problem. Too much overview/restrictions will get over ridden and the result can be not good. It may also be a matter of overwork, which often is the case in medical situations. There is, like always, no perfect answer. But at the same time as several have said, many warnings, many steps here were over looked. That may be the norm at this facility, or it may not, we don’t work there and don’t know. Those that do, should.
I have been on a med for some years and had seemingly unrelated issues. That word seemingly is doing a lot of work here. 3 weeks ago I had an appointment with a doc who is very, very good. We discussed my meds because of the increase in symptoms that should be unrelated to this med that another doc had increased my dosage of. The results were NOT GOOD and I stopped taking the increase. The good doc suggested that I split up the dosage to twice a day, a very unusual procedure for this drug. The difference in my life is amazing. My tremor is gone. I had some docs telling me I might have Parkinsons because of my tremor. I don’t. I also don’t have tremor any longer and my life is dramatically better, just by a simple idea, not of total daily prescription strength but of splitting the same dosage. I need the medication, just not all at once. This is outside the normal concept of this drug. But I am obviously not normal, which is obvious by my reactions to many drugs, this very normal and very prescribed one is an example. The medical profession is rather rigid in it’s thinking, and it should be because that has made MOST situations far, far better for outcomes. But not every situation/human is the same and there has to be a range of acceptance of that fact. Both my case and the case of this nurse giving the wrong medication can be an indication of the same problem but from different directions because we don’t all think alike, act alike, react alike, are not all assembled alike.
Rules are absolutely necessary but they can not be so rigid that they get ignored and they must have some flexibility for those that are outside the normal. And maybe it possible that similar named drugs should not be next to each other in one place so that it is easy to mix them up. But possibly that could make a specific situation worse by making it harder to find a particular drug. In a modern world of more choices it gets harder to always be correct.
Barbara
@waysel:@waysel: The article was interesting. One thing it noted was that the nurse typed in “Ve” to engage the automated dispensing system and didn’t look at the name of the drug that the system spit out. The article suggested that there are some drugs for which you should be required to type in at least 4 or 5 characters to avoid getting the wrong drug that begins with the same letters. It’s hard to disagree with that.
Le Comte de Monte Cristo, fka Edmund Dantes
As tort reform expands and damage caps get baked into the system, expect more of these, inasmuch victims and their families don’t get compensated for loss and wind up expecting justice from other sources.
Facilities and insurers live this shit – they can offload their liability onto the lowest rungs of the ladder.
Alison Rose ???
@trollhattan: Now to see if Murkowski and Romney follow suit.
Eljai
This article has a timeline. If I’m understanding correctly, the original medical examiner determined that the patient died due to the brain injury because Vanderbilt didn’t report the medication mix-up. After an investigation, the cause of death was attributed to vecuronium. So, if the nurse had not admitted her mistake, it seems there’s a likelihood that she never would have been charged. It’s troubling. I certainly don’t advocate for carelessness, but she did admit her mistake right up front.
Feckless
RN to patient ratio everywhere is horrible.
BC that is how hospitals turn a Profit, understaffing.
Oclday
206inKY
@Cervantes: Agree completely. The fact that both drugs start with the letters “Ve-“ make it obvious that this wasn’t intentional.
Wonder if the system populated the rest of the field after the first few letters to save time. Or if these warning signs were alerts that accompany every drug. If so this prosecution is even more egregious.
Barbara
@206inKY: It was obviously not intentional, but she must have realized that there is more than one drug that begins with the letters “Ve.” I am not necessarily comfortable with criminal prosecution here, but it bothers me that the standard of care would be established in a way that normalizes errors in an automated system. Why bother with humans at all if they are not required to correct or check a system that is known to be so imperfect?
piratedan
@206inKY: on many systems, there’s a pattern match process in play, so it may have defaulted to the last VE entry, not necessarily to the alphabetical one…..
Barbara
@Eljai: I don’t know if that’s the case. The system would have recorded the dispensing of the wrong drug, if someone bothered to review it.
jl
” the Vanderbilt UMC should for cutting corners and not having actual pharmacists ”
I don’t think we know enough from the reports whether putting the nurse on trial was justified, and just as important, whether Vanderbilt has been held to the same standard.
I hope that the Vanderbilit UMC system was put through a very fine comb. The lack of actual pharmacists is a red flag to me, or any similarly trained personnel to replace them. There are pharmacists and pharm techs who specialize in nothing but designing and monitoring and doing continuous quality control on drug distribution systems. They look at every little detail.
The very idea that two different drugs with vary different characteristics and risks would be stored in the same cabinet seems not up to standard to me. And the idea that any modern distribution system would involve anyone choosing drugs from something called a ‘cabinet’ sounds strange. I’ve done stats for projects on quality control from drug distribution systems, and some of the story signals a bad system to me. I want to hear more about the details of how it works (or doesn’t work).
Geminid
@Alison Rose ???: I’ve got Burr (NC) and Cassidy (LA) on my list of long shots to vote for Judge Brown. Reasoning: In 2010 Burr broke with his caucus to vote to end the “Don’t ask, Don’t tell” system discriminating against openly gay service members, and is now retiring; Cassidy broke with his caucus to vote for conviction in the second impeachment trial. Cassidy says he is considering a run for Governor of Louisiana in 2023.
Laertes
For her to be criminally liable, there has to be some criminal intent. It’s not enough to show that she made a mistake, that the mistake fell below the standard of care, and that that mistake harmed her patient. That gets you to medical malpractice, but to get to criminal negligence you need to show that her technique was so egregiously flawed that she knew or or should have known that she was endangering her patients.
That’s gonna be a highly fact-sensitive determination, and I feel like I don’t have a clear enough view of the facts to have a well-informed opinion. Those warnings she ignored, for instance? That may or may not be significant. If it was the usual custom and practice in her workplace to disregard them, then this wouldn’t demonstrate criminal negligence on the part of the nurse, but might inculpate her higher-ups.
At bottom, it’s about a simple question: Was the chain of decisions that resulted in the error so egregiously sloppy that it demonstrates willful disregard for the safety of her patients, and not just an overworked line nurse working in a significantly flawed environment.
Just on the facts I’ve got in hand, I can’t tell.
Villago Delenda Est
Prosecute the MBA assholes who set this whole thing up.
Barbara
@jl: The article linked to above made the same point, which I did as well — it was probably an error to store such a potentially deadly product, Vecuronium, in an automated system like this. But as for the absence of pharmacists — it’s just not that unusual, but especially in an outpatient setting where patients are being administered twilight sedation for minor surgical procedures.
206inKY
“At the time, they said, Vanderbilt was struggling with a problem that prevented communication between its electronic health records, medication cabinets and the hospital pharmacy. This was causing delays at accessing medications, and the hospital’s short-term workaround was to override the safeguards on the cabinets so they could get drugs quickly as needed.”
https://www.tennessean.com/story/news/health/2020/03/03/vanderbilt-nurse-radonda-vaught-arrested-reckless-homicide-vecuronium-error/4826562002/
When a workaround to override warnings becomes standard procedure, the blame is clearly institutional.
The nurse also immediately told the truth, whereas Vanderbilt engaged in a lengthy coverup. This is like something out of Kafka.
https://www.tennessean.com/story/news/crime/2022/03/25/radonda-vaught-speaks-out-jury-verdict-homicide-trial/7167520001/
Jim, Foolish Literalist
@Geminid: I just saw Tillis is a no, I thought the open seat and recent narrow margins in NC might make him want to put a moderate face the state party.
The committee is now deadlocked 11-11 on advancing her nomination to a full vote, which I gather will pointlessly slow things down but not stop the process
Hoodie
Seems like a very questionable case. Docs often get away with far worse carelessness. Also wonder if there are grounds for appeal on the issue of recklessness.
Looks like normal civil negligence to me. People ignore warnings from automated systems all the time because they’re often wrong. Medical personnel turn off alarms all the time. Why does this system allow overrides without requiring someone with an alternate id (e.g., a supervisor or other nurse) to verify that the override is correct? Gee, if a fucking grocery checkout requires a manager override, why wouldn’t this piece of shit? Seems like her own admissions may have hurt her, which underscores the possible effects of criminal prosecution for such acts – people will hide errors.
jl
@jl: for example, no bar code scanning system that tracks the Rx to the correct patient and dosing time? Were verbal orders allowed for risky medications? What were the ‘no verbal orders’ rule for that system? (or BJ pedants, I guess it should be ‘oral orders’, but I’m not in charge of official jargon. ‘Verbal orders’ is the standard term in many fields).
And as other commenters have noted, warning fatigue is a real problem in medicine. In poorly designed systems clinicians get warnings on such a regular basis that it has become more than a issue of personnel staying alert, investigating everyone pushes staff up against hard time constraints in getting things done.
IMHO, the description of the drug distribution system throws up some red flags for me.
206inKY
Also from that article: “Overriding was something we did as a part of our practice every day,” Vaught said. “You couldn’t get a bag of fluids for a patient without using an override function.”
jl
@Barbara: Sure, but I wasn’t talking about clinical pharmacists on the clinic floor to kibbits around on every Rx. I was talking about distributional pharmacists, or similar dedicated drug distribution quality control staff. Vanderbilt is a large system, hard for me to believe they didn’t have someone.
Barbara
@jl: Right, but I think the biggest issue I would have is that she dispensed the wrong drug and didn’t check to see that it was the right drug. Even if the warning system was utterly useless, it just seems like anytime you dispense a drug you need to look to see that you have dispensed the drug that was actually ordered. That’s the hardest thing for me to view as an institutional failure, though systems could be in place to prevent or avoid that kind of failure as well — like an alert that says, “this drug has not been ordered for this patient,” or even, “this drug cannot be dispensed without a physician order for this patient.”
SeattleDem
I used to be on the safety committee at a not-for-profit medical center and can say that at that set of facilities there is a team that investigated thoroughly and made recommendations for how to prevent a recurrence of errors that caused or could have caused serious harm. The “multiple Warnings, so ignore them” protocol sounds to me like a reason to yank the automated dispensing system until the real warnings are separated from the chaff. I’m an IT guy, so I don’t buy arguments about fixing software being too hard or expensive. Distracted and tired people do stupid things, so it is up to the facility to make sure there are as few opportunities for harmful effects as possible.
IMHO, the manufacturers or implementers of the software should pay the price, not the nurse whose mistakes and conditioned responses were the final chain of errors.
jl
@Hoodie: In poorly designed systems, staff would not be able by any human standard, to get their work done if they investigated and checked on every warning.
I will admit to some preconceived notions when I hear about these kinds of mistakes. I’ve seen how the sausage is made at a couple of large medical centers. The work conditions are horrible, the money suits routinely cut corners, shift costs and risks in the name of bogus ‘efficiency’ onto staff. Often in ways that would put Putin to shame as a piker.
I think the management should be first in line for a very thorough investigation whenever a serious medical error is made. In sum, ‘I seen things’. There are established system quality standards, and they should be considered part of the standard of care, just as much as anything and individual clinician does, but they very seldom are.
Cassandra
@Villago Delenda Est: I agree. She was negligent and the consequences were that someone died…but I fail to see how she was criminal. The closest thing to criminal intent here is the hospital’s willingness to compromise quality of care in order to make money. You are talking about a mistake that could have been prevented by a protocol of having a second person verify the drug correctness. We all know why that doesn’t happen.
Moreover I don’t see what positive thing comes from making the nurse suffer prison. The hospital procedures will remain unchanged. More people will decide to leave nursing. As a society, this decision makes things worse, not better. This is not the same as locking up a dangerous criminal.
jl
@Barbara: Any human being hits limits beyond which consistent reliable performance is simply impossible. That has been known since aviation systems become so complicated that test pilots became routinely killing themselves in crashes in WWII.
For example, if the coding system for the drug identifiers was not up to standard (and there are very well known industry standards) the Vanderbilt drug distribution system should share liability, both civil and criminal, IMHO.
Larry B
My sister is a recently retired ICU nurse with 34 years in medical and surgical ICU experience. She is beyond enraged by this decision. The US health care system has increasingly prioritized profits over patient care, reducing the number of nurses, increasing their workload, extending their daily hours. It’s a miracle, or actually it’s because nurses work miracles, that more cases like this don’t happen every day. The only way medical care systems get better is through the honest reporting by the professionals who make mistakes and own up to them. This decision is nuts. She made a mistake. She admitted it. Medical professionals make mistakes all the time. There is a process to fix the problems that allows those mistakes to happen. If the corporate overlords of medicine weren’t working nurses to death, depression or career change, the risk of these events wouldn’t be so high. It’s understandable the family was devastated. Turning honest medical mistakes into crimes will drive more nurses out of the profession, degrade health care and risk everyone’s health and well being. Just one more monumentally stupid decision.
Martin
@Cervantes: Agreed.
To expand on this, other professions do hold individuals accountable in this manner, but in very different circumstances. An engineer who makes a mistake designing a bridge had basically unlimited time to review that design, get colleagues to review, run simulations, do more math, and so on. The one variable they can’t use as an excuse for getting it wrong is *time*.
This is where process comes into play. If you know that *time* is your independent variable, you gotta invest a fucking fortune in process. While we shouldn’t conflate health care with industrial process, but we can learn a bit about industrial process. A car assembly line is also time sensitive. Stopping that line is a failure of the process – it means someone failed to do the job correctly within the timeframe allotted (same basic situation). The core competency of automakers is solving this problem. It’s not designing cars. It’s making sure the center console is correctly installed in less than 60 seconds. (This is the thing Tesla utterly sucks at). This is what ‘The Toyota Way’ does. If you need to hold that console in place with 4 screws, and you drop one, there are backup screws in a specific place, orientation, and so on. The worker doesn’t go and fish around on the ground for it. It’s a small thing, but when time is your independent variable, it’s all small things that add up to to critical problems.
Part of how you solve this is sweating ALL the details. But because *time* is the constraint, you also solve it with staffing. You worry less about whether everyone is always occupied with something to do, and worry more about whether someone is always available and in proximity of a patient to treat them with as much time made available as possible to actually think through the task. This is why the military doesn’t put efficiency at their top priority, but effectiveness. A bunch of guys sitting around waiting isn’t a problem to be solved. The problem to be solved is taking the hill, and you don’t cut back on that because a bunch of guys are sitting around waiting.
There are a lot of details here that we can’t possibly know, but one thing we do know is that everyone in the US preaches at the church of payroll efficiency and workers are constantly being in put in the position of performing a task that *must* be done in 60 seconds and which cannot possibly be done in less than 55 seconds. If you drop the screw on the ground, you’re fucked, and then you get prosecuted.
These are the kinds of things that you want clear standards and best practices documented that you can judge whether the working conditions were designed to help the employee succeed or whether they’re designed to help them fail. A crazy number of processes are designed to help the employee fail.
evodevo
@Suzanne: Well, that’s not good..on the other hand, Versed is a tranquilizer, like Valium, so if someone did check, and the patient was sedated, they would have had to take the time to note that there was no respiration, and done a code blue…would they have noticed that the patient wasn’t breathing? Or would they just have glanced in and not seen anything abnormal…and gone on about their business… Who knows…Both the nurse and the hospital were negligent and deserve penalties, but I would think it would only be criminal if there was some intent or this was an ongoing problem.
Chacal Charles Calthrop
@MFA: to err is human, but to really screw up you need a computer.
jl
To understand what I’m getting at, read ‘The Checklist Manifesto’ by Atul Gawande.
The very idea that any clinician could put their hand in something called a cabinet, and grab drugs with such different properties, and no mention of a bar code check for drug delivery and administration sends up red flags and sirens to me.
There are very explicit, well known, validated quality standards for drug distribution systems in any place where lethal drugs are prescribed. Was Vanderbilt up to standard or not? Simple question with a simple answer. Yes or no. What is it?
Martin
@Villago Delenda Est:
Lacking the details to fully know what happened here, this is statistically the most likely answer. And it’s not even close, IMO.
Paul in KY
I think she should have been convicted of something. The bad drug she gave had all kinds of warning labels on it & a trained professional like her should have known something was hinky & gone to an MD to confirm.
206inKY
@Barbara: Definitely. Regardless of systems, there’s the basic step of just reading the label, and this is no doubt a mistake that merits termination.
But it’s also clear that they were processing overrides for every single medication as a workaround until the tech issues could be fixed. Once a workaround becomes embedded in standard procedure, the warnings are all effectively invisible since there’s no way to know which were real and which were simply a product of the electronic records issue. This puts even more weight on the human step of reading the label and matching it to the requested drug.
The common starting letters of “ve-“ and immediate admission of error seem to decisively show that this wasn’t criminal behavior in a context of institutional procedures that effectively eliminated safeguards until the electronic records problem could be fixed.
Hoodie
@jl: In that context, this system not only useless, it conditions people to rely on the system instead of doing manual checks. These things a typically put in for the putative reason that they cut down on errors, but they often do the reverse, especially when they don’t work. As you note, this usually goes hand in hand with the subtext that some MBA whiz kid probably also sold this as a way to cut down on personnel costs, e.g., another nurse or pharmacy tech so this doesn’t just add to the list of tasks the charge nurses have to do.
It’s funny. My kid has a bunch of friends who work for one of the major consulting firms. These kids are in their twenties, smart but don’t know shit about anything. Yet, they’re “consultants,” even though most of their experience is doing case studies in MBA programs. These firms bill them out at exorbitant fees, kind of like big law used to bill high-dollar associates for drudgery like document discovery. At least with the law firms, those associates didn’t do much damage. They were just overpriced.
Suzanne
@206inKY:
This should not be interpreted as any sort of defense, but it is the case that hospital IT systems are often a mess. There’s no standard for EHRs and hospitals often struggle to get the information they need. Info security has suffered. Some hospital systems have been victims of ransomware attacks. I have no doubt that the nurses knew that this was a problem but just had no better way to get through the day.
That’s the problem with the Swiss cheese model of protection…. when every layer fails, it’s difficult to apportion blame to specific layers.
jl
@206inKY: There are also well-known quality control standards for how how drugs are placed (adjacent or far away from each other) identified so minimize possible confusion. It’s a whole fricken field of research how to arrange placement and ID of drugs when you pick them.
Martin
I’m gonna assume that ‘RaDonda’ was a variable in the decision to prosecute criminally. This is of a pattern in the US legal system.
Paul in KY
@Old School: Kim Potter meant to kill that dude. She’s a cold murderer, IMO.
Alison Rose ???
@Geminid: Interesting. Based on that, I could see both of those happening.
Suzanne
@jl:
My experience is in the design of the physical space to support this process, not the design of the process itself…. but everything I have read about this is very similar to what I have seen in the dozens (if not hundreds) of hospitals I have observed in a professional capacity. The IT problems are obviously bad, but it is the case that they are bad in a typical way. Healthcare workers often are presented with situations in which conformance to professional standard is not feasible.
What I do not think is within professional standard is the 25-minute period in which the patient was left unobserved after being given that drug. But again, if a nurse has too many patients, they often simply cannot meet the standard. I don’t think we know why this happened.
evodevo
@jl: Yes…this…why would you have a drug that closely resembles curare, and therefore is extremely deadly if mishandled, and would only be used to entubate for anesthesia, in the same “cabinet” with a mild tranquilizer? Seems a system ripe for medical mistakes.
jl
@Suzanne: ‘Vanderbilt was struggling’
That’s a red flag right there. If they were ‘struggling’ with very serious system problems, CMS should have been threatening to yank several certifications and fed and state inspection teams should have been all over the place. (But after looking at S’s comment, it is true that substandard systems are commonly allowed until someone suffers a preventable death)
Basically what that says is that this society permits a multimillion dollar institution to ‘struggle’ with allowing substandard system with no sanctions a all. But a human being faces sanctions for failing to compensate for a negligent system while being overworked.
I think something is very fishy with the story, and it’s not just the issue of whether this nurse should be criminally liable.
Edit: I’d like to know how long this valiant ‘struggle’ supposedly waged by Vanderbilt had gone on.
Old School
Here is an interview with RaDonda Vaught while she was waiting for the verdict.
Eunicecycle
I know my daughter is freaking out about it. She’s an NP now so doesn’t give meds but she thinks it is wrong. Lose her license, absolutely, but going to jail is too much.
Suzanne
@jl:
I agree with you. But I would be willing to bet a lot of money that if Vanderbilt was struggling with this issue, probably half of American hospitals are/were also struggling with it. And taking down hospital capacity in a community also puts lives at risk.
Also, most US hospitals use Joint Commission or DNV to maintain their CMS accreditation and to do their inspections. CMS doesn’t do them directly. Every inspection I’ve ever seen uncovers issues (“findings”) but very few would be considered so grievous as to result in taking beds offline even temporarily.
Dangerman
Nurse going to jail; Trump going golfing. Strange days.
Bottom line, sounds like a grievous error that resulted in death. Shoulda known better and blew through some stop signs. Awfully damn reckless.
Suzanne
Ironically, one of the most common findings in hospitals in physical plant inspection is actually often caused by IT, and that is punching holes in smoke-and fire-rated barriers to pull cabling through. Now there are various rated sleeve products.
Paul in KY
@evodevo: That is fucked up. Hopefully that has been changed.
jl
@Suzanne: “most US hospitals use Joint Commission or DNV to maintain their CMS accreditation”
That is a good point. That’s how it works until someone gets crippled or dies. I don’t think either one is designed to detect emerging quality control issues that lead to these types of clinical errors. I haven’t taught the stats of how these systems work and how institutions are rated for a while, but last I knew, they use crummy proxy measures for quality standards in many critical areas that can, and have been, gamed.
jl
@Suzanne: And taking down beds is not the first step. You threaten to yank any certification or license that the institution requires to rake in the money. Suddenly, weirdly, the struggling ends and problems get fixed. Funny how that works.
tokyokie
As a nurse, obviously I am not pleased with this outcome. Early on in nursing school, students have the 5 rights of medication administration hammered into them: Right patient, right drug, right dose, right route, right time. The physician’s order is supposed to be triple-checked before the drug is administered, but I’m wondering what was the form of the physician’s order. Entered into the computer system? Given over the phone? That the order was for “Versed” makes me think it was probably an oral order of some sort, because the dispensing machines use the generic names. “Versed” is the brand name for midazolam, a benzodiazapine anxiolytic. It should have been ordered by the generic name, not the brand name, although physicians routinely fail to do so. The medications would be stored in the dispensing machine under its generic name, not its brand name, and as the meds are generally arranged alphabetically, the verconium would have been in a different drawer that she should not have been able to access. The nurse has to take responsibility for administering the wrong medication, but the physician who ordered the medication by its brand name and the pharmacy folks who hadn’t programmed the med dispensing machine to block retrieval of a med from the wrong drawer should get some of the blame as well.
JCJ
@Suzanne: This is exactly the big concern for me. If the patient had been given the proper drug (midazolam) she should have been monitored.
Suzanne
@jl:
Nah, medical errors happen all the time. They’re really common. That’s how it works AND someone gets crippled or dies.
“To Err is Human” is over 20 years old now, but it terrified the hell out of the healthcare industry. At the time, they estimated 98,000 deaths a year due to errors in healthcare delivery. I’ve seen more recent estimates that call that figure into question, but by any decent estimate, it’s still a fuckload.
Suzanne
@jl: Be realistic. Do you honestly think that, had an inspector observed that their meds dispensing equipment software needed to be upgraded in order to interface correctly with their electronic medical record software that they had to do it immediately?! No way. There would be something like a three-month period for correction at least. Some of my clients have been given a year to correct big problems, the kind of problems that could conceivably result in serious harm. In the meantime, nurses have to keep working because people are still sick. Again, none of this is to excuse, but to give context.
There have to be multiple layers of protection because there will almost always be failures along the way.
jl
@Suzanne: Yes, you are correct. I got overenthusiastic, but I think I did correct myself in a previous comment. Nothing really happens until someone is maimed or dead, and a preventable, and direct, and proximal, and difficult to sweep under the rug, and pinnable on staff, obvious medical error of some kind is the cause
trollhattan
@tokyokie:
Excellent information and background, thanks!
Attended a university with a pharmacy school, and had a lot of pharm major friends. The degree, especially PharmD. is rigorous and they graduate (and pass the boards) with far more pharmacology than M.D.s receive. The “model” if you will, is for doctor and pharmacist to collaborate on prescriptions, and for the pharmacy to be a central point for evaluation of all the patient’s medications, since as one gets older one has more and more doctors prescribing, typically with little cross-checking.
My mother, and mother in law both had points in their lives where a new physician evaluated their entire medication protocol and made needed wholesale changes, due to mismanagement and in some instances, eliminating antagonistic parings. I assume this is an issue for most seniors, right now.
jl
@Suzanne: By standards of comparably, supposedly developed high income countries, US medical care is very sloppy and full of mistakes. Other countries with much more highly rated health care systems were similarly sloppy in the past but were able to correct the problem enough to be better than we are. France is one example. But we just carry on as usual with a mess. Edit: Portugal another example.
cwmoss
@Cameron: they’ve always been able to claim negligence. That’s what the system of medical malpractice deals with. Now they’ll get to claim negligent homicide.
Fake Irishman
@The Moar You Know:
FYI everyone: nurse was fired and lost her license before this. She’ll never work a day again as a nurse. Not sure what tossing her in prison will accomplish.
context: my wife is a VA physician who works on safety and quality improvement research. She’s not happy about this at all because it encourages people to cover up their mistakes instead of reporting them so we can fix underlying system problems. It really undermines the entire idea of a root cause analysis. It also ignores the fact that the medical dispensing cabinet had several design flaws in its search function that made this problem more likely (for example the search functions only required two letters of a drug before it started spitting out potential medications, which drastically increases the likelihood of selecting the wrong medication).
Low Key Swagger
@jl: Long thread and I’m catching up. I’m pretty familiar with this hospital. A few years ago, Vanderbilt Hospital decided to “split” from the University. Ever since, they have gone through a ridiculous number or database systems, and have struggled to have information flow easily between the adult side and the childrens hospital. I have long been amazed at the low quality management in nearly every dept. Lastly, they still have not gotten their nurses up to market value, tho they freely acknowledge this and seem to be working on it.
Oh, has anybody written about this Nurses’ employment record? had there been protocol snafus in the past? How were her reviews? I think her record should be considered.
tokyokie
There seems to be a misperception in this thread as to how medications are distributed in health-care facilities. In hospitals, the vast majority of medications are stocked in medication-dispensing systems. The meds that go in there are the ones used the most often, and they’ll be stocked in a variety of dosages. (The dosages are usually small, so the 40 mg tab one takes at home may come as two 20 mg tabs in the hospital.) Each different medication, and each different dose of each medication, is stored in a different bin, and the machine will have about 10 drawers, each holding about 50 bins. Sometimes meds like insulin will be in multidose vials; the nurse draws the amount of insulin ordered for the patient and puts the vial back in the bin. But for the most part, the bins contain tablets or capsules. The nurse can only withdraw the medication and dosage that he/she scans or types into the computer. That will unlock the drawer and bin for the medication, and until another med is scanned or typed in, he/she can’t access any others.
Pharmacists keep these machines stocked, with the computer system alerting the pharmacy department when supplies of a particular dose of a medication are running low. Hospital pharmacists’ medication compounding duties are, for the most part, limited to IV fluids. They’ll have lots of bags of standard fluids, like 1000 ml normal saline, but if the provider wants to administer a medication with the IV fluid, a pharmacy tech will mix it up and send it up to the appropriate section of the hospital. IV antibiotics, by and large, are sent up from pharmacy, probably because a lot of them require refrigeration, but need to be warmed to room temperature before administraiton. But hospital pharmacy techs aren’t compounding meds from scratch in tablet form.
Kent
She should have been fired and lost her license. Which actually happened. But I’m uneasy at putting her on trial and giving her jail time. I’m not sure what that serves. But jail time is indeed what we do to cops who make similar mistakes, as has been pointed out here.
As for the victim’s family? I expect they should have pretty good grounds for a civil malpractice suit against the hospital. Which was also to some extent at fault for this tragedy.
Cacti
Are all the elements of negligence there?
Duty of care? Yes
Breach of duty? Yes
Actual cause? Yes
Proximate cause? Yes
Damages? Yes
Negligence by definition is unintentional, so I believe her completely when she says she didn’t mean for it to happen. But saying “oops, sorry I killed you” doesn’t make it all better.
tokyokie
@JCJ:
That gets us to the issue of staffing levels. If the nurse had too many patients to handle, which is not uncommon, she could have been flying through the process of acquiring and administering the drug because she had to tend to a couple or three other patients before making her way back to the victim. I’m surprised that didn’t come up in the news stories about the case.
J R in WV
Having spent quite a bit of time in Hospital over the past few years with Wife, the nurses are the people who actually save lives by implementing Dr’s orders. They straighten out confusing orders and verify that orders make sense for a given patient’s condition. Doctors are in and out, perhaps spending 8 minutes in a patient’s room. Nurses are there way more.
No way this was criminal. She didn’t have any criminal intent, couldn’t have had. As others have said, the drug handling “system” was a complete failure, and in order to treat patients they had to misuse it multiple times a day. Whoever provided that “system” committed the crimes here, for money.
catclub
Maybe this has already been brought up, but since the pharmacy cabinet should be connected to a computer,
why is the choice of drug not linked to patient prescriptions? instead of asking for drug X, ask for medications for patient John smith dob 01,01,1951 ?
the match of veconium(?) with versed is super scary
catclub
@J R in WV: I did not see your comment when I made mine. This sounds right to me, too.
Freemark
Hospital has heavy responsibility
catclub
@Freemark: sure looks like the DA was looking for whoever had the least money to hire legal representation.
Jon Marcus
@Oclday: How is this different from Kim Potter? Potter was trying to harm her victim. Vaught was trying to help her victim. Intent matters, especially in a criminal case.
I’m down with firing her, and taking her license. She should not be going to jail.
Another difference: Vaught immediately and voluntarily reported her mistake. We want to encourage and maintain that behavior. Mistakes like this happen thousands of times a year. It will be much worse for patients when nurses start trying to cover them up for fear of going to jail.
Ohio Mom
@Ruckus: Late to this thread but I am happy for your good news — no more tremors, hooray!
I know someone else who also benefited from taking a half dose in the morning and the other at night, for a med that usually isn’t taken that way, for a completely different condition than yours. Maybe this is an approach that should be used more often?
Geminid
I know very little about these matters but can observe that there are a lot of knowledgeable and perceptive people commenting in this forum.
StringOnAStick
@Suzanne: wow:
If she’d given the correct drug, Versed, the patient should not have been left alone and not checked on. Versed can cause such deep respiratory depression that the patient “forgets” to breathe, so there needs to be someone monitoring that and yelling at the patient “take deep breaths NOW”. I’ve seen this happen IRL. People on Versed can follow orders even though deeply sedated, and if being told aggressively to breathe doesn’t work then there’s equipment nearby and available. That she left the patient alone for so long after giving the Versed is negligent, unless she’d turned them over to someone else’s care. I just can’t imagine giving Versed then walking away isn’t against a whole lot of rules.
Mai Naem mobile
Sentencing her to prison is just a bad bad idea. Forget getting anybody to admit to medical errors again. She should lose her license and face some civil charges.
StringOnAStick
@StringOnAStick: After reading the rest of this, having a automatic system that autofills on drugs on just the first two letters seems like a huge part of the problem. Even just requiring the first 3 letters would have made a huge difference.
The real issue though is staffing levels. For profit medicine has a lot of sins to answer for.
tokyokie
Midazolam administered IM has an onset of about 15 minutes, and a peak of 30-60 minutes, so checking on the patient after 25 minutes doesn’t seem too far out of line. But vecuronium, which she administered, is supposed to be given in a weight-based dose, administered IV push, has an onset of 3-4 minutes, and a duration of 25-30 minutes, which makes not checking on the patient until 25 minutes had passed really bad. Frankly, I’m surprised that vecuronium was even in the med-dispensing machine. It’s a medication primarily given by anesthesiologists and CRNAs, not RNs.
And I agree with you in regard to staffing levels. Overburdened nurses take shortcuts. And the medication-dispensing machines should only acknowledge the generic, not the brand names.
Ruckus
@Fake Irishman:
I am a VA patient and have been operated on and put under on more than one occasion. Every single step of the way there is a check list that everyone has to go through, and I don’t mean on paper. Any time I see someone different in the chain of being a patient I am asked my name and number. Every time there is a new prescription I have to talk to the pharmacist to insure I know what I’m getting. Yes it takes a moment, yes it is a pain in the you know where, yes I am over joyed at this level of attention to detail on my behalf. And still it is not perfect, mainly because everyone involved is human and yes, some are a bit more human than others. Still it is a workable system. When I had an operation, every person that was going to be in the room while I was under and being cut up came by to introduce themselves and let me know their face and name. I’ve never seen that anywhere else.
Ruckus
@Ohio Mom:
Yes, it should be considered far more often in my opinion.
This doctor is one of my favorites of all the docs in my life. And I’ve been lucky and had quite a few good ones. And a few that have me thinking “fuck off asshole,” and that one that I actually did tell “Fuck Off.” But this guy is the first to tell me and show me why, after almost 6 yrs of yes/maybe, that I don’t have Parkinsons. And then to find out why and come up with a solution for 98% of my tremor, right in front of me? Yeah he gets favored status. He earned favored status. And he has followed up with messages on the VA system. Only one other doc has been this good/thorough for me and that was my radiation oncologist, also at the VA. I’ve had good docs before, this is different.
Bmaccnm
@evodevo: Recently retired RN with 35 years experience in ICU, ICU, and high-risk OB here. I have a multitude of questions about this case. Nurses don’t usually administer vecuronium, CRNAs and anesthesiologists do, because of the lethal potential. Vec is given only in the presence of resuscitation equipment. Electronic dispensing stations only dispense one medication at a time. All meds are in separated, locked cabinets and only the med you request is unlocked. Versed is a brand name for midazolam, which is what the nurse should have requested, not Versed- I don’t understand how she confused the two, unless the pharmacy tech made an error stocking the med station. Even if she believed she was giving Versed, she should have observed the patient after giving an IV medication.
Ultimately, it comes down to the 5 Rs- Right medication, right patient, right route, right dose, right time. MBAs aren’t responsible for this. Professional nurses are. I don’t know if this warrants a prison sentence, but as someone else said above, the nurse has a duty of safety and care.
Bmaccnm
And, Tokyokie, I hadn’t seen your comments when I made mine. Yours are more precise than mine.
Another Scott
@Cervantes: I think this is where I come down as well.
My elderly FIL was in rehab for a while (after breaking some ribs in a fall). He was on a time-release morphine pill to control his back pain from his scoliosis. He had to eat pureed food. The overworked nurses at the rehab place ground up all his pills – including the time-release morphine – to mix in his food.
:-(
The staff all thought he was bedridden because he was always out of it. They didn’t believe us that he was fine before he fell…
Eventually, we figured out what the problem was and he recovered. And we got him out of there ASAP…
People make mistakes. Overworked people working in bad systems make more mistakes. Medical mistakes can, and do, kill people.
A systemic mistake killed the patient. She should not be subject to criminal prosecution here.
My $0.02.
Thanks.
Cheers,
Scott.
Felanius Kootea
@Bmaccnm: From one of the linked articles shared, the computer system for the medication cabinet was set up in such a way that she was allowed to type “ve” for versed but that pulled up vecuronium instead. She was negligent in not checking that there this was the wrong drug beginning with “ve,” but there is a larger problem than just her negligence here. If the sole focus becomes the nurse, the unfortunate thing is that the same problem can recur with other drugs (if the system allows just two letters to dispense a drug with no other checks). She was negligent and there was a design failure. It is possible that with a more efficient medication dispensing design, the accident would not have occurred.
Lepercorn
@Barbara: I know. Versed is not a common medication for a floor nurse to use. It’s basically used in anesthesia most commonly for conscious sedation. It’s also used in drips in ICUs to sedate people on the vent. I have to wonder what department she worked in and why she didn’t know what it is. Still should not be a murder case.
Inspectrix
I’m a VA physician. I am in a position where I promote open disclosure of all safety concerns and every workday starts with a safety huddle.
I read part of the evidence in this case that I think is legit. Contrary to speculation, she stated that she was not overworked or overtired. It’s clear to me that she made multiple errors in judgment that led to this terrible outcome.
https://www.documentcloud.org/documents/6785652-RaDonda-Vaught-DA-Discovery
She was at fault for her part AND there were clear systems issues that allowed this to happen. This was very hole-y Swiss cheese. The computer warnings she bypassed multiple times, the fact that she was able to leave the patient after injection with the PET scanner tech. What was the hospital protocol for IV sedation? Either IV injection would have required very close monitoring. An ICU nurse who is seasoned enough to be teaching a student, as she was that very day, would have know vecuronium is used in very specialized circumstances. She described herself as distracted but by what?
she was appropriately fired and reported to the state licensure board who in turn should have removed her license. I agree with all of that. I am as concerned as others that we need more self disclosure of errors as she did right away and this criminal case might deter others from reporting errors.
She was part of a broken system and the broken system should be held accountable.
Egorelick
My opinion. The jury made the decision. There was certainly enough for an indictment. Chilling effect? I think people are being innumerate when they state this. The 250,000 deaths because of medical error a year are not of this kind. This kind of egregious error happens once or twice a year. One thing I firmly believe is that this wasn’t her first mistake; it was just the first one that killed someone. My (likely unpopular) two cents. (Full disclosure: full time pharmacist and 1st year law student)
Biogeojim
my wife is an ex-ICU nurse and she is horrified by this case. Aside from many of the points raised above, she pointed out to me that in emergency situations verbal orders are very common, because the order entry process for doctors is quite time consuming. Which means she had to override warnings all the time to execute verbal orders. This is a tragic mistake but an even worse decision to prosecute and convict.
Original Lee
@206inKY: This. The nurse went through the nursing board process TWICE. It wasn’t until Medicare got shirty about Vanderbilt not reporting the mix-up that the criminal prosecution got wheels. And by an amazing coincidence, the DA handling the criminal prosecution has connections to Vanderbilt.
While most of the discussions have been on the impact on nursing, the EMTs have also been pointing out the chilling effect on them. Grrrrr.
BellyCat
Remarkable thread. Nurse is pursued for hospital’s systemic failures. One disposable head rolls instead of many publicly important heads. Justice in ‘Murrica! ™
Partner is a an ICU Doc. Very pro-Nurse and pro-systems improvement. She is horrified by this. Nurses (and everyone else) will refuse to admit errors for fear of criminal culpability and systems will create more and bigger issues with decreased error reporting.
Healthcare in ‘Murrica! ™
SamIAm
@Betty Cracker:
I think it’s just to criminalize mistakes when people die or suffer life long disabilities.
This seems to me to be a very clear, bright line. Why is ANYONE second guessing this? Speaking as someone who has over a half dozen relatives in the medical profession.
My sister, who’s been an RN for thirty years reaction was; “No fucking excuses after you ignored safety protocols. Through her ass in jail.”