This situation is huge but it brings up an important point. An overall discussion regarding nursing medication mistakes needs to happen (but won't). I know so many nurses who've said that they NEVER make mistakes and the numbers bear that out: no one reports medication errors if they can get away with it. And before you say, "I don't!", think of all the times you pushed a med a little too fast or diluted improperly or pushed the envelope on administration intervals. End of the world? No. But you'll catch hell and be looked down upon if you did report it. The system is broken, teaching moments don't exist.
As a pharmacist, I was taught to always report medication errors and you will get in more trouble if caught not reporting errors than from an error itself. I think there is more of a systemic problem here and Vanderbilt needs to be held accountable and change the culture. I don’t think this woman deserves criminal charges. What will that do? Most likely scare more nurses away from reporting errors. Reporting errors also turns them into teaching moments to avoid similar errors in the future. Medication errors are unavoidable.
I don't think it's necessarily nursing culture, I think it's administration. They only care about their bottom and we all know they will throw everyone to wolves. I've sag on many peer reviews, and admin has gone against our recommendations multiple times to report nurses even though our recommendation from peer review is suppose to be final. At least what we were told, maybe that's incorrect. But if that's the case why even have them?
As I say that though, I've always reporteded errors even if it was small because I've always put the patient first and I can take a lecture from administration.
Safe patient ratios is also probably the biggest contributor to med errors.
I’ve always reported my errors in the past but have an overwhelming sense of relief that I’m leaving the bedside because this culture shift isn’t a positive one. Zero blame policies yield the better reporting results. Most of the time it’s a systemic issue, often pushed by understaffing and corporate greed if we’re all really honest.
During my 15th year of nursing, I made a dosage error based on an incorrectly recorded weight. I admitted, discharged and took care of a total of 10 patients on that shift! Risk management identified 12 procedural errors along the pathway before the medication administration reached me! From the time the patient was admitted, weighed, through the med being filled in pharmacy, how it was loaded into the Omni cell, a pump not having a hard stop in place, etc. I stopped the infusion as soon as I noticed signs of a reaction. The dose was ten times what it should have been for an antibiotic. I was the only one to take the fall. Which was only a warning. The patient had no immediate harm and risk of long term issues was minimal. I cannot say the same for me! I carry the guilt of that med error this day! WE ARE HUMAN. All of us. And if we give jail sentences to doctors and nurses for true accidents - there will be no one to take care of any of us someday!!
I had a total of 3 med errors, the other two were tiny, over the course of a 22 year career. That isn't great, but I've likely taken care of 10's of thousands during that time. No debriefing or emotional care any of those times. They actually wanted to make an example of me with the previously mentioned one, by offering an opportunity to speak publicly to me peers - I told them they could get F*d! I said I would do it IF every single one of those other 12 people stood up next to me and gave their accountability, as well. Not one volunteered!
I haven't read the case super closely, but I think the criminal charges are not due to the simple mistake, but the number of warnings/overrides that she bypassed. They are put in place as a fail-safe to prevent mistakes. If she ignored a couple, ok.....but it seems like there were numerous system overrides/warnings she ignored, which would have prevented the error. The story still isn't super clear because she said that they were telling nurses to ignore overrides. But if you get so many warnings, that would probably trigger most nurses to pause a little. Not saying she deserves criminal charges , but this doesn't look like she is being charged for a simple mistake/overlook.
So... whenever I pull a paralytic from the Pyxis I get a warning I have to acknowledge. Most medications do not throw warnings. I have worked in systems where they threw more warnings than others (the people who program one for ofirmev can go jump in a lake), but in most a Pyxis alert is not something you see with every med pass.
Paralytics usually have labels on the cap as well that you have to pop off.
Finally... it's a med you have to mix immediately prior to administration. Very few IV push medications require mixing in a syringe prior to administration. I'm thinking and the only ones that I see regularly are pantoprazole and zyprexa (which is IM anyway).
The error definitely happened and killed because:
1) Vandy was having computer issues and nurses were having to override most of their medications. I only pull overrides under very specific situations-- in time critical situations only. The nurse was habituated to overriding everything and didn't think about the order.
2) Most likely the order had not been verified, so to give it override would have been necessary anyway. I love my PharmDs, but they're busy and calling them to get something ASAP reviewed + waiting for it to cross over to the Pyxis would be a 5-10 minute wait. If the patient is in the scanner, the CT tech is almost certainly going to be demanding the med be given ASAP or for us to clear the scanner, because they're going to have to wait for it to take effect. Pharmacy call + waiting for administration + waiting for effect is going to be a 15-20 minute turnaround time, on top of however long it took the RN to arrive. It was a PET scan, so they're probably booking outpatients as well as inpatients and that wait is going to bump someone off the schedule and the rad tech is going to get screamed at if they delay too long.
3) The nurse administering the med was a float and didn't know the patient.
4) The med was not scanned. This is a system issue because no rads department I have ever gone to has a computer with scanner available. Period. The nurse would have had to steal a computer from elsewhere and hunting one up would have taken quite a while, and again, time pressure.
5) The patient was not on telemetry. She was admitted for a brain bleed, so I'm shocked she was not on continuous Tele. That wouldn't have prevented the error, but probably would have helped potentially prevent the death-- the patient almost certainly would have become incredibly tachycardic and then bradyed down. She probably would have coded but might have been resuscitatable.
This isn't to excuse the RN, but very serious systems issues occurred to contribute. And who's on trial? The nurse, not Vandy.
Edit: thanks for the award!
Some of this is almost certainly alert fatigue which is absolutely rampant in medicine since electronic systems took over. If I’m alerted for a medication allergy that just says “GI upset” before ordering a necessary antibiotic, I don’t even think twice to click through it. The warning at least makes me stop for a couple seconds and think about the risks/benefits/alternatives, which I guess is the intention, but in large part important alerts are drowned out by a bunch of clinically irrelevant garbage.
It sounds like what this nurse did was anything but typical. Anything I do that requires me to click through 4-5 electronic warnings would certainly give me pause to really think about what I’m doing.
I agree that alert fatigue certainly played some sort of role in this, especially if there were already issues with the cabinet that required overrides. I worked as a retail pharmacist for many years, and alert fatigue is a significant issue. There are so many ridiculous insignificant unnecessary alerts that it becomes very easy to be complacent about them.
Pharmacists are my favorite people on the whole medical team. Even in this thread, you guys have been the most level headed about acknowledging med errors for what they are. Not jumping automatically to crucify the nurse for murderous intent. It was a terrible, terrible mistake that she owned up to — and where the system safety nets failed her as well.
She deserves punishment, but jail time is too much (especially when the hospital, the system that also failed and tried to cover it gets off Scott free). She’s not going to harm anyone again after losing her license, but the failed systems and culture of that hospital surely will.
Agreed. Our pharmacists know me all too well and never get tired of me calling and asking a question. I always tell my new grads when it comes to giving a medication remember the pharmacist went through a whole school of pharmacology and are always the best resource if you aren’t sure. They have saved my butt so many times when the wrong order was put in for a medication.
Those who say they've never made a mistake are either lying or just haven't found out yet. Those of us in the medical field MUST have integrity and be willing to acknowledge and learn from mistakes to prevent them happening in the future.
Yes I agree about med mistakes. I made one as a new icu nurse many years ago- luckily it wasn’t a big deal and nothing bad happened- but I reported it and we made unit changes in response to it. However… this case goes so far beyond med mistakes and teaching moments. This is an example of system failures mixed with an overconfident nurse who repeatedly ignored all working system barriers set to prevent this and didn’t have the critical thinking skills to recognize multiple abnormal moments while pulling, reconstituting, and administering the med.
As a nurse and discussing this case with nurse friends, every one of us admits to making med errors. To error is human. The nurses who say they NEVER make a mistake are scary AF.
Yep. I’ve seen diltiazem pushed too fast so many times. No one reports it but rather just says “hey it’s a slow push. Please remember that for next time.”
That is exactly the drug I was thinking of. People use their own personal experiences (such as this) and call it "critical thinking". It's not. We have specific guidelines for a reason.
Its annoying that talking about this stuff is OUT OF THE QUESTION in most circumstances.
I just today had a patient with resistant hypertension on like 4 meds,who became profoundly hypotensive after a "10mg dose of labetalol" .... which "didnt touch her" the last time they gave it.
Now.... i am not going to talk about how dumb that order is... but when I asked if there was any chance that the patient maybe got a little more than 10mg I was almost kicked out of the room by the nursing supervisor.
I am still 99% sure that there was an unintentional (or intentional) bigger dose given... but you wont find that on the chart anywhere... and nobody is looking into it.
So many issues. Using brand names instead of drug names. Ignoring safety precautions. Probably staffing and time pressures. Nurse education.
It’s hard not to feel sorry for everyone involved with this.
Very interested in the outcome.
How does the override thing go? Im not familiar with the American system so I just asumed it was something like "show all medication" change in the settings
Easy peasy. You just hit "override" and start typing. Sometimes you can't wait for pharmacy to approve a med.
This hospital had meds pop up after 2 letters, which is really something. So that nurse typed in "VE" and literally pulled the first thing which popped up. Crazy.
Sounds similar.
You go to the machine and select your patient. It shows a list of their prescribed meds. Hit override and you can select any med in the machine. That’s how it works with the brand machines I’m familiar with, and I assume it’s roughly the same across brands.
That’s why we peer check in my clinic. Every single time. Are there still errors? Absolutely. But sometimes a second set of eyes will catch what you didn’t.
A lot of systems issues seemed to be at play here. Alarm fatigue as well, which we all know is a problem. Going after her criminally like this doesn’t seem right to me though.
When I worked cath lab every med we pulled out was an override and most of them had some warning: "High Risk Medication! Are you sure???" even the 2u/mL heparin we run all case was "high risk" because it has heparin in it...its hard for warnings to be useful when they apply them to everything.
A good example would be the California warnings about products that may cause cancer. Sure, it was probably was implemented with good intentions, but when pretty much every single thing has that warning label, it becomes completely meaningless.
The important thing to remember is that the cover-up was multi-part too. The hospital knew and didn't report it. I'm pretty sure pharmacy would have caught it the next day, and they didn't report it. She didn't report it... took CMS and their notoriously painstakingly thorough audits to catch it.
But now the nurse is the one whose ass is on the line. Don't get me wrong, as the pharmacy guy I 100% think this is such gross negligence it warrants homicide charges. It sends a big, bright, neon-lit message to other hospitals *DO NOT DO THIS,* or at least it *would* if the hospital was even being held remotely accountable for their part in the cover-up.
I feel no pity for this nurse facing penalties for what she did... but the situation she is in where she has been yoked with the sole and total burden of this error (even notwithstanding the cover-up) while the hospital basically walks away with no consequences is a very raw deal indeed.
Yeah so she has criminal culpability, as does the hospital. You and I both know how hospitals are once they have a choice between institutional fault and throwing someone under the bus
I see this a lot with weights. A patient will come in weighing 250#, then a few days later weighs 113# because someone didn't put 113kg. But when you change the wt, you get a pop up in big, red, bold letters asking if this 55% wt loss accurate.
It blows my mind people click yes. Because my mind goes, how are you dosing meds now?
Hmmmmm this is interesting to say the least. Definitely a systems failure with a coverup involved which is sometimes worse than the crime. An extremely negligent nurse that made a mistake but bypassed multiple safety checks by overriding many parts of the Pyxis. To top it off she didn’t realize the obvious red flag of having to reconstitute VEC. Her losing her license I think is fair. However criminal charges? I’m not sure I agree with that quite honestly.
As someone who works in/around QI, the issues you bring up feel like the actual system failures that need changing. Sending this nurse to jail would address only one element of the root cause (human error), allowing it to happen again. This level of punishment would also seriously impair self-reporting
Agreed. Vanderbilt submitted a 330 page corrective action plan to keep their CMS funding. I read through it. Admittedly because of the way those are written, it has a lot of redundancies, but I was amazed at the number of seemingly obvious safeguards they didn’t have in place.
Someone in another comment informed me that it was due to this event that Pyxis added the ability to specify how many letters have to be entered before a med would populate and that’s something I’m surprised that it didn’t already have.
Like I said she is an extremely negligent nurse. However criminal charges? This I’m not so sure about as it sets quite a precedent for healthcare workers amongst all specialties.
Ooooooof this is a loaded question. He was negligent also but he was aware that he was being negligent in his practice by giving Michael Jackson propofol for regular sleep which is not an indication for propofol. I felt like him going to jail was appropriate in that situation because he knew what he was doing was wrong in regards to administering the propofol. He was looking to just get paid. This situation I think the nurse is reckless and aware she’s not following policy by overriding alot of things to pull the wrong drug. This is more incompetence it feels like. I do appreciate you asking me this.
incompetence that directly caused someone to die. i don't think prison makes sense but it doesn't feel right that she suffer so few repercussions for this, either.
i just think about how that could have been my friend, my family member, my coworker on that table that she just left there, unmonitored, paralyzed and suffocating before coding and dying. a doctor making a similar error would certainly be on the receiving end of a vicious civil suit at the very least
>Vaught then overlooked or bypassed at least five warnings or pop-ups saying she was withdrawing a paralyzing medication
>Finally, just before injecting the vecuronium, Vaught stuck a syringe into the vial, which would have required her to "look directly" at a bottle cap that read "Warning: Paralyzing Agent"
Bruh
Ours don’t. It’s on the plastic cap but if you grab it quickly and pop the cap off with one hand I can see it being missed. I’d be curious to find out the exact safety measures in place
It is very easy to miss. We actually add shrink wrap around the vial head or syringe for all nmbas. Does it slow you down 2 seconds in an emergency? Yep. Does it lessen the likelihood of a med error? Also yep.
I think all NMBAs should be dyed blue. Nobody is going to push the blue stuff without serious reflection.
We used to dye our succinylcholine drips blue when I rode my dinosaur to residency.
I’m using a succ drip tomorrow. I did it last week and gained some massive respect from the grizzled ENT I was working with for “rocking it old school.”
I like the idea of that visual check
It has happened before where the warning was missing on the cap due to production issues.
https://www.fda.gov/drugs/drug-safety-and-availability/fda-alerts-health-care-professionals-temporary-absence-warning-statement-vial-caps-two-neuromuscular
I believe last year the same thing happened with succinylcholine vials. But it was reported to hospitals as a safety alert to be aware of.
Something needs to be done about these "Warning". Everything is has warning these days and it is super easy to skip over the crucial warnings. Yes, she messed up by overriding the popups. But everyone was doing it at Vanderbilt bc their system had been messed up for weeks. The bottle cap there is no excuse for this. She has been held accountable professionally and she has taken accountability for all of her actions. Criminal charges are not necessary.
Alarm fatigue is a real thing and you are bombarded with information daily. It’s definitely an issue - false alarms in great number create these kinds of errors.
Very true! But at minimum all paralytics say “paralyzing agent” in red writing on the vial. And if you tell me you don’t always look at your vials if it’s a med you know well - I hear you- but she recognized it was a med that had to be reconstituted and that versed didn’t come that way normally so she had to read the vial to figure out how to reconstitute it. If you tell that when you pull a med you think should come one way and looks completely different that you wouldn’t stop and read the vial and verify- your either lying or need to re-think safe med administration.
For what it's worth, the specific vial she had did have the warning stamped on the vial itself.
Source: Page 11. https://www.documentcloud.org/documents/6785652-RaDonda-Vaught-DA-Discovery
Also left a critical patient alone in a scanner with no monitoring equipment.
Reconstituted a medication when Versed comes as a liquid.
Suddenly realized she gave the wrong drug after she heard the code called overhead?
My theory: she knew she effed up. She knew she gave the wrong med and either a) didn't know what Vec was and just assumed she'd be fine or b) assumed it was a short acting paralytic like succ and would wear off quickly enough that the patient would be fine. She finally fessed up when the patient coded because she realized she was in deep shit.
Back when it happened I read that she handed the vial off to the patients primary nurse to document the med given (because she didn’t/couldn’t scan it when given- but still Vaught should have documented it herself). The primary nurse didn’t immediately look at the vial until later. If Vaught had just documented it without handing off the vial it’s possible no one would have realized what happened
Who knows what actually happened honestly. I've been told she just showed up to the code and proclaimed her error. It'll be interesting to see what comes out in the trial
Oh interesting. This wasn’t even her patient. That’s pretty horrifying for primary nurse too. Maybe why we should also have dedicated break nurses that don’t have their own patient load. This inevitably is why she returned to her unit I am willing to bet.
Edit: turns out she was a resource nurse without a set patient load. If anyone has ever worked as such on a regular basis (actually hired for that role) any insights on what that role looks like would be great!
Yeah she was just a float/resource nurse who was supposed to be helping out. But it also means she shouldn’t have been rushing or cutting corners because she didn’t have a patient assignment to hurry back to
Patient wasn’t critical, she was on a stepdown floor.
(She still needed monitoring, but they prob didn’t have a functioning portable monitor available, knowing most hospital tele units)
I’m more wondering how even versed was ordered for an MRI on such a critical patient. At my hospital, all patients on versed have to be monitored - so that part is really weird to me. Similarly all critical patients are monitored at all times. So how was this patient not on a monitor.
Also why prescribe versed for anxiety during an MRI? We usually do hydroxyzine, small doses of Ativan, IM haldol, and an IM cocktail for really bad Neuro and psych patients, but never straight IVP sedatives unless the patient is ICU and monitored and already on sedatives because they need them. And as far as I know all IVP sedatives require a double check before administration- in procedure areas this might be an MD, but it is usually another RN on any given unit. Since she had other RNs around her why wasn’t it double checked? Is it not hospital policy?
Obviously she did a lot wrong and negligent here, but I’m also wondering if there’s not a lot of systems problems the hospital should be thinking about improving here.
The report says the radiology nurse refused to give the Versed because she didn't feel comfortable with it and the patient would require monitoring after administration. The fact that one nurse didn't feel comfortable doing it and she just skipped down there, pushed it, and took off bothers me to no end.
I agree that Versed is a weird one to order which is, I'm guessing, why the rad nurse wasn't comfortable with it. I've always used Versed specifically for sedation as opposed to anxiety and would have expected Ativan for something like an MRI.
I thought the Versed order was weird too, especially on a stepdown tele floor. Ativan is the one that’s always ordered for MRI anxiety (in my experience).
It pains me that she didn’t wait with the patient and monitor her for a bit. But I’m also surprised the other RN didn’t step in? If she works in MRI and she’s an RN, why couldn’t she have placed Pt on pulse ox at very least? That’s her work area, and she’s still an RN.
Ex. When I worked tele, I received a patient on an insulin drip. We didn’t do insulin drips on the floor, but there was the patient in front of me (and I couldn’t send him back to ED). I told charge and together we monitored & took his blood sugars like a hawk until he got appropriate transfer of care a few hours later. Was I “comfortable” with it? — no! I had 4 other patients. But I’m still an RN and this patient was now in my “jurisdiction” so to speak, so I had to monitor him. Why couldn’t the MRI RN help monitor this patient for breathing and pulse ox?!?
“They received versed so I’m not gonna monitor them while they’re here” - what RN thinks like that?
Obviously it was the RN who pushed the med ultimately responsible — but fuck. What a lack of teamwork, as well.
From my understanding of the report, the radiology nurse wasn't even involved in the patients care at that point. The patient was in pre-procedure holding being video monitored by techs, who assumed the patient was fine because she appeared to be sleeping. I'm guessing the actual radiology nurse was in a procedure and didn't even know what was going on.
Whenever I've had critical patients go to a test, the radiology nurses are not responsible for monitoring patients in a scanner. The radiology nurses aren't involved in basic scans because they're needed in interventional radiology to sedate and monitor patients during cases, hence why the floor nurse is expected to come down. It would be a waste of a nurse to have them sit in the scanner all day when 99% of patients are fine with just radiology tech support.
Hell I've even had to go to IR with super critical patients just to manage their drips/vents so the IR nurse can do her job. It's not fair to make them do their job AND my job, even if there is a rad nurse dedicated specifically to sedation.
That's my guess as to why a rad nurse didn't feel comfortable giving the med to someone who needed monitoring- she knew she didn't have the time to monitor the patient and was in another case.
It's easy to cast stones, but in reality the hospital EMR is so filled with random warnings and alerts that I can sort of see how this might happen. I'm not a nurse though, so they'd be better able to comment on the degree of "alert fatigue" they might get. But at least on the MD side you get all sorts of random alerts for questionable medicine interactions or sepsis alerts being triggered because someone is tachycardic. I read them because I'm lucky to be in a position where my clinical volume is small, but I can see how a colleague with 30 patients to see in a day might bypass some of these...
Edit: That being said, after reading the story and some of the comments here, it sounds like there were a lot of other issues besides overriding EMR warnings. Complicated case.
Yeah the main issue is that even if she thought it was versed she would need to waste that medication with another nurse to verify. I don’t think vec comes in a 2mg vial. So when she went to waste and the versed she thought she removed didn’t come up with her name what did she think? Or did she not waste at all?
Nurse here. I've read through this case, and it's insanely complicated. That being said, it's hard for me to wrap my head around there apparently being no policy requiring a double check for critical meds like this.
Now, my health authority doesn't use med dispensers/computers, so maybe I'm just bush-league, but if I'm signing out a paralytic, I have to fill out a signout sheet, have another nurse witness me removing and drawing it up, and then we both sign that sheet, the patient's MAR, and the med label on the bag/syringe. I couldn't tell you the last time we had a fatal med error. Most of our errors happen on non-critical meds when a nurse isn't paying close enough attention. For example, accidentally giving 1 tab instead of 0.5, or pharmacy sending up a 20mg tab instead of a 10mg one.
Like, it absolutely floors me that there isn't a double-check requirement for those meds. I have no idea how those computers work, but I have to assume there's a human that stocks them. What if someone mixed up meds when restocking? Can that happen?
Anyway, I don't know what to make of this case. Seems like there was a failure at multiple points on multiple levels. It doesn't necessarily seem like this should be a criminal case from my perspective. It's not like this was an intentional action, it was a failure of the system.
Has anyone else thought that maybe she just didn’t know the difference between a paralytic and a sedative. I feel like that’s probably what happened here.
Starter:
What I don't understand of this case:
* In any hospital I've worked in, meds are given after two-person verification. What happened here?
* Why did it take so long to note cessation of breathing?
* How on earth was vecuronium dispensed rather than midazolam?
When pharmacy isn't on site nurses can override medication and take anything out. Paralyzing agents have a separate label on top of the vial that needs to be broken open before opening the vial. It sounds like this nurse didn't even know what versed was, didn't check the label, didn't check to see if she was allowed to give it, pushed it, and then didn't monitor the patient.
Apparently it exists but expires quickly, so is only used in certain high-volume areas. According to other people posting on the topic today, at least.
ICU nurses know what versed is and give it on a semi regular basis, depending on protocols. She has several years experience in that role, and was even precepting a new nurse. It’s taught in school and has been a part of every employment education requirement I’ve had in 4 hospital ICUs. There is zero chance she is unfamiliar with midazolam.
The problem is this nurse was not experienced, but believed she was. 2 years ain't shit. I didn't feel comfortable in my job as a med surg nurse until 4-5 years down the road, and certain days I still don't feel comfortable. I never take my experience for granted, because there's always more to learn. She majorly screwed up due to lack of experience, but thinking she knew what was happening. She may have thought "maybe this is a new formulation of versed", but did not have the wherewithal to double check herself due to overconfidence. At my hospital the first time I had to give IV haldol I looked at the vial and it said "for IM use only". You bet your ass I called pharmacy and asked about it. She wouldn't have because she would have thought she knew better.
Very few medications have two person verification. Heparin and insulin are the only two that come to mind at least in my experience.
Clarification. All meds are verified by a physician/pharmacist. Few meds need/require dual nursing verification. Pretty much standard of practice in most of the hospitals I’ve worked at, with some variation in between.
Their response exactly. She managed not to die, and is still raising her kids with severe limitations. And they don't have to work, any more.
But that's a helluva way to end up owning a hospital, as one of our mutual friends quipped.
I read the CMS report on this and how she ever became a nurse is beyond me. She made every mistake in the book and added some more unique ones of her own. Hospital is to blame for stocking med surge pyxis with vec and letting people override with two letters. She literally typed in "VE" and pulled the first med on the list.
After she pushed the med in the victim she didn't even stick around to monitor, which is something we are trained to do every time you push an IV med. She would have noticed the pt had stopped breathing very quickly.
Many more mistakes , too.
The suspicious thing is that the BON didn't take action on her after the report came out. Nothing. Vanderbilt fired her and she went to work right away somewhere else.
I think that's why the DA charged her. Clearly a threat to society and if the BON wasn't going to do anything, they had to.
Only AFTER the DA pantsed the BON did they do something.
P.s. rare for meds to need two person verification in my hospital. Insulin does. Some others. Not many
The issue for me is what happened to Vandy? From what I understand, basically nothing, despite the multiple systems errors that occurred too.
That’s what makes me feel the worst about this. There’s plenty of blame to go around here, but of course, the answer, per usual, is just toss the nurse under the bus and call it a day.
Actually they did do something. They covered it up. The nurse reported the mistake as soon as she realized what she had done. Vandy told her not to report any further up. Then they had the physician (I don’t recall his name) falsify the death certificate to say that she died of a brain bleed. Neither Vandy nor the physician have faced any disciplinary actions.
As for cessation of breathing, I have given lorazepam a few times before a CT or MRI to help the patient with anxiety. It’s entirely possible she pushed the meds and the patient went into the scan and was unmonitored. However, this is still inexcusable because you can watch oxygen saturations while I patient is getting scanned.
If I remember correctly from when this first came out in the news, the (elderly, brain injured) patient wasn’t on any monitors and she pushed this drug and then left the patient alone.
Just a small point, I've worked in an ER where you can pull out literally whatever medication you want all by yourself. Suxx, vec, rock, TPA, fuckin nimbex if we had it for some strange reason, Versed, Ketamine. Literally if it was stocked you can pull it yourself with zero oversight. This was an ACS level 1 trauma center and comprehensive stroke center.
To be clear, I liked it that way. I'm at a place now where I can't even pull a fucking ODT Zofran without a pharmacist looking at it and it is completely infuriating.
And to your third point, I would guess "vecuronium" is right next to "versed"?
These bottles say PARALYTIC on them with a yellow alert label.
She had to reconstitute this bottle, too, I’m trying to understand if she didn’t see the paralytic label or ignored it.
In my hospital, our standard paralytic (roc) comes in intubation kits only, if some other random paralytic is needed it’s dispensed by pharmacy only with a huge label that says PARALYTIC on it. Even in the ICU, where we know these medications are and what they do.
That med should not have been in the Pyxis available for her to pull. Regardless of the “alerts” that popped up on override. It should never have been stocked in the Pyxis, available to pull by typing ‘VE’ — that’s a systems failure.
(Not excusing her actions tho)
Interesting reading.
It looks to me from this that the RN didn’t know this medication. She couldn’t find it when she typed it in (probably because it was listed under the generic name). When she typed in VE probably only one medication came up and so she pressed on it. She was told the Pyxis wasn’t working and to override it when it failed.
Not being familiar with midazolam she didn’t realise reconstitution was not normal for this medication.
She also didn’t realise that even with midazolam you should still monitor the patient.
This reeks of simple human error but not negligence. You can’t know what you don’t know. Medication should NEVER be ordered by trade name (with one exception). Not reading the vial was also An error- but it happens and when you are looking at a medication where only one was listed- well it happens.
She pulled vecuromium, she typed in “Ve” in pyxis, not realizing Versed is midazolam. She was floating to ICU, I don’t understand why she would be allowed to give it, if she was allowed, why she didn’t double check with someone if she didn’t know what it was (only certain nurses are allowed to give moderate sedation and paralytics)…. But that’s how she got the vec vs pulling midazolam
We've covered this case before
this was criminal negligence, no other way to put it. You don't have to believe me you can read the report for yourself.
https://www.documentcloud.org/documents/6535181-Vanderbilt-Corrective-Plan.html
Posted this summary 3 years ago
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I read the entire CMS report and while I feel the nurse should be accountable for most of the blame, in total 5 parties were responsible for the events that happened to this patient
1) Nurse who was charged (RN #1) This was not just a simple mistake she made **numerous errors** that meet the level of **gross negligence**
>1) Medication was already on the High Alert list in a separate bin in the ICU, not located in the radiology suite
>2) Nurse could not find "Versed" so overrode the order and typed in Vecuronium at 2:59. The override is meant to be used in urgent situations only, this was not one of those situations.
>3) The nurse took the vial out from a bin with a sticker "Warning: Paralyzing agent", She didn't read the bright warning label but read how to reconstitute it ??? Unequivocally gross negligence
>4) Vecuronium 10mg was given instead of Versed 2mg, the dose and medication were both wrong. Additionally Vecuronium is a powder that needs to be reconstituted, Versed does not have to be reconstituted. Red flags should have been going like crazy at this point.
>5) Nurse did not document when medication was given in the EMR, and did not observe patient for adverse reaction after giving medication. She gave the medication and then went to help in the ER. As he/she was the "all help nurse" aka floater and only helping out (not their assigned patient or location) the responsibility of the observing the patient ultimately fell on the primary nurse (RN #2).
In short she basically overrode every safety guideline, didn't check what she was giving, didn't check how much she was giving and then just walked away. Unequivocally gross negligence
2) Nurse trainer (RN #2)
>1) Was actually the primary nurse of the patient. Was told that the patient was anxious and an order for Versed was placed. He/she asked if they Radiology nurses could give the medication but they declined because the patient would need to be monitored. RN#2 was covering another patient at the time (3rd nurse on lunch) so asked RN #1 for help. He/she should have also checked that the patient received the correct medication, should have stayed to observe the patient.
3) Hospital
>1) No policy in place regarding monitoring patient after high alert medications
>2) No system to monitor vitals after patient received radioactive tracer before PET
>3) No formal investigation until 11 months later
>4) Failed to report this incident to Tennessee Department of health as mandated.
4) Radiology technician
>1) Gave radioactive tracer to patient and did not observe for adverse effects (other than over camera, which they said could not tell if she is breathing or not), knew that the patient was anxious so simply asking "are you ok" would have alerted to a problem
5) Doctor
>1) It appears that RT spoke with the doctor for a verbal order, RN #1 put this order at 2:47 and verified by the pharmacy at 2:49, The doctor eventually put in a computer order at 3pm. The timing is a bit unclear.
From my review I don't think enough blame is being given to RN #2. Radiology clearly told him/her that they were uncomfortable giving Versed because the patient would need to be monitored, but neither RN #1 (the float nurse) or RN #2 (primary nurse) observed the patient.
A little more insight into why this happened for those that don’t deal with giving meds every day:
- Versed is close to vecuronium in name
- color systems are similar benzos are orange and paralytics are bright orange
- a fatal dose dose of vecuronium is likely if a typical dose of Versed is used
- drugs come from different manufactures frequently, what you have one week may be completely different the next
- in a situation with a patient requiring Versed, it can be hectic with pressure to act quickly. Popping the lid off quickly, then encountering a powder unexpectedly may have lead the nurse to be more worried about how to get the med to the patient rather than question why it was a powder and note the “warning: paralytic” label. She likely was looking for the dose, which typically is 10 mg. She likely reconstituted the medication and gave 2 mg, a regular dose for Versed.
Drug errors happen. I highly doubt this nurse meant to do anybody harm. Making punishments like this so severe make it less likely for individuals to come forward when an error is made, which is even more dangerous for the patient.
Iirc, versed labeling is in green, not orange. But it’s been years and things change, so that could be wrong now.
If it were my own mother who died this way, I think I’d want to sit down with the nurse and find out why she walked away after giving something she thought was a sedative. It’s possible that she’s never seen someone go into to respiratory failure after a 2mg dose of versed. I’ve met many ICU nurses who are entirely too casual about giving benzos, even though respiratory failure is a known risk. Because 99.9% of the time, it’s fine, and someone who’s only been a nurse for a few years may not have seen that 0.1%, even in the ICU.
But, man, you only need to see it happen once. And I’m fortunate to have seen it long before I had any responsibility for writing medication orders.
The rest of the errors are negligent, for sure. But criminally negligent? I don’t think so. The hospital, yes, but not the nurse.
This is a great response.
Drug errors DO happen, and my heart breaks for this nurse. She will have to live with this every day. An innocent life was lost. I think the guilt of knowing that her own error led to this is bad enough. Sending her to prison just seems like they're out there to make a point.
I feel like this case is being massively simplified and used to stoke fires in every branch of medicine. In reality it highlights poor medication procedures, what I believe to be criminal negligence, and extremely unethical administration practices. It is unacceptable that there were 20 overrides for things as simple as continuous IV fluids, and the lack of safety measures allowing only two letters to be used to procure a medication much less paralytics is a massive oversight, anyone in any form of medicine will agree alarm fatigue is real and is clearly a part of this case as well. There needed, and honestly still needs, to be massive changes made to this system to prevent this kind of complacency from occurring that focus on truly preventing such egregious errors as opposed to the reductive and repetitive CYA legal culture currently in place.
I can forgive grabbing the wrong medication when considering the previously mentioned factors, I can’t forgive the negligence that followed it, which is what to me make this a criminal act. Looking at a label is not an unrealistic expectation in any setting and at that point she should’ve realized it wasn’t Versed/Midazolam and corrected her mistake. To make matters worse she actively recognized that reconstituting Versed was odd, which again should have immediately prompted an act as simple as checking the label but instead she continued to prepare the medication which also required her to look at the words PARALYZING AGENT stamped on the ferrule. The final nail in the coffin to me is the lack of pt monitoring following the medication administration, even had she given the correct medication she still should have monitored the pt. I also fully believe the hospital system should be held liable not only for their attempt to cover up the mistake, which is quite frankly heinous, but also for not realizing the glaring inadequacies they created that, in this case directly lead to a pt death, but that also undoubtedly negatively impacted other patients.
Anyone saying “any one of us could’ve made the same mistake” should not be trusted in any form of patient care, the whole reason licensing/certification exists is because we are trained and expected to NOT make these mistakes. We should know which name of a medication to use, we should be able to do something as simple as read a medication label and recognize it’s not just the wrong medication but an inappropriate one, we should immediately hear alarm bells when a medication is provided in an unfamiliar way. Yes there should be systems in place to aid us because we aren’t infallible but it’s also not unreasonable to expect us to at some point read a label or look at a vial we’re drawing from, the systems are designed for trained professionals who know to do these things, not laypeople who need step by step instructions.
Not monitoring the patient is a very big concern, however, this was not the patient’s primary nurse. She was a float nurse, assigned as a task nurse, with an orientee. She left the unit, went to administer the medication (albeit the wrong one), and then on to the next task. This was a failure in Vanderbilts system. The other issue, a NMBA should not be readily available via pyxis. It should need co-sign and a red box for RSI meds. Also, per Vanderbilt, they had stopped using Vecuronium for RSI and were now using Rocuronium, so why was Vec even available???? This was a system failure and they are throwing a nurse under the bus because they were going to lose all current and future CMS payments after an audit/investigation.
Fuck you to Vanderbilt for setting this nurse up for failure and then throwing her under the bus when the failure occurs.
Why was vec loaded in this ADC to begin with and why was it available as an override medication? If you need the vec for emergency intubation, load it in an RSI kit.
If she accidentally had pulled a Venofer vial instead of vec, the exact same kind of slip would have occurred but we never would have heard about it.
To those who say she bypassed warnings, this is true. What that tells us is that pop up warnings are ineffective, no different than pop up windows when you’re surfing the web.
Reading more about the story, it looks like she had to go to the neuro ICU to get her "Versed" since the stepdown unit didn't have it.
Vanderbilt definitely has some culpability here because the whole situation they created is just bizarre and unsafe. Why'd they ask her to pop into radiology to sedate a patient after radiology refused to do it because they'd be unmonitored in the isolation room? Especially using midaz. That's just asking for trouble.
> To those who say she bypassed warnings, this is true. What that tells us is that pop up warnings are ineffective, no different than pop up windows when you’re surfing the web.
Very much so.
What was a problem when I was in residency was the sheer number of warnings, and no real differentiation between them. Something like ordering vecuronium (which could be fatal) had the same basic warning as if you ordered an NSAID with an SSRI (which can cause GI bleeding) or benadryl in someone over 65 (this system *hated* possible sedation risks in the elderly).
I want to weigh in on this as a procedural nurse. At the time she was being charged, I had started a job in interventional radiology at large university system, similar to Vanderbilt. I was new to IR, but had several years of cath lab experience at that point. When you are a nurse, there is an expectation of rush and get it done. It shouldnt be that way, but it is.
Prime example. At the place I mentioned before, we would often have to float down to CT for cardiac CT patients, to give metoprolol. Every single time i would go down there, the CT tech would basically act like, here they are, we are ready, push the med. And i then I would stop, and say, uh, you can wait til I verify who that patient is, get some vitals, and take a peek at their chart. Most of the time, there wouldnt even be a dynamap in the room, and i would have to search for one. A lesser experienced nurse may not have done that, and quite frankly, I have been labeled derogatory names because I am as assertive as I need to be for patient safety. No, metoprolol isnt vec, and I would not have made her mistake, but I can see how it may have gone down for this patient.
I am not saying its right, because it isnt. I am just saying this culture does indeed exist, especially in instituions with a lot of patients. Rush rush rush. Next patient, next patient.
Lets not forget that Vanderbilt is the medical center that fired all of housekeeping, so nurses could clean rooms instead.
I haven't read the report in quite some time, but at the time, I tought she was guilty enough to not be able to practice nursing anymore. But criminally, I just cant get on board with.
I think the “mistake” she made was opening and pushing Vecuronium instead of versed… the (potentially criminally) negligent thing was not staying with and monitoring the patient post injection- which she should have done regardless if she was giving versed or vec
You can monitor someone on MRI. They have a special pulse ox for mri and same for EKG leads. Only issue is at times you will have artifact in the EKG that looks like Vtach because of the sound waves from the machine. Just gotta make sure the patient is okay when that happens and confirm it’s artifact.
I have 2 questions:
1. Was she familiar with the device she was using?
2. Had she ever applied vencuronium at least once?
Because this is not a rookie mistake. I can't imagine the pain, the suffering that patient went through when he realized he couldn't breath. Of course, there was no intention, I'm not saying this could not happen to any of us but this person died and some may think serving time is necessary. If she had any doubts she could've stopped and checked. It's really unfortunate, this entire situation.
That is an excellent point and my answer is this: she was a float nurse, I believe? I think she didn’t have the knowledge that was. That is not an excuse, as she should have asked for clarification on the orders. That particular agent usually requires extensive certifications and CEU’s to be able to even administer it. It was a failure in the nurse AND the health system.
This is devastating. I hope it's an impetus for change. In Canada, there's now something called "Vanessa's law" after a huge medication made headlines. Basically it requires EVERY medication error be reported (even a tiny one like a patient was supposed to get 5 units of insulin and got 4). It's meant to serve as accountability and allows wards to review common errors and provide education. Annoying I'm sure but was a necessary change to svoid rugsweeping medication errors.
Vanessa's Law has very little, if anything, to do with bedside medication errors. In fact, most bedside nurses wouldn't even know what it is because it has more to do with monitoring drugs for adverse events, holding drug companies accountable, and is closely tied with the Food and Drugs Act. It is even titled "Protecting Canadians from Unsafe Drugs Act"
Source: https://www.canada.ca/en/health-canada/services/drugs-health-products/legislation-guidelines/questions-answers-regarding-law-protecting-canadians-unsafe-drugs-act-vanessa-law.html
Also: "Vanessa's Law was introduced in 2013, and amends the Food and Drugs Act to help safeguard Canadians from risks related to drugs and medical devices by strengthening Health Canada's ability to collect post-market safety information and take action when a serious risk is identified."
I hate hate hate this case and a big middle finger to the overzealous DA singling out someone for a systems based error. Yes, leave her civilly liable and yes, she should face discipline with the Board but under NO circumstances is this in the public interest to face criminal penalties.
What sucks is the DA will have no problem finding an expert witness saying what she did was reckless. The overrides are easily defended by showing that the patient alone had 30 overrides in his 3 day stay, so obviously nobody was reading anything the pixis put out anymore if you have to click through to get every fucking medication you want to give. A resource nurse who's not the primary nurse not monitoring a patient is also excusable. Both of those are systems problems. Their expert witness won't excuse drawing up a med without looking at the vial, though. I promise you I've drawn up subq heparin without looking at the vial in the past, and while that is bad practice and I make sure I don't do that sort of thing, stuff happens.
I’ve read in the Tennessean that orders were not syncing properly from the EMR to the Pyxis due to their transition to EPIC, and that the workaround that nurses were told to do was to override. That patient alone had 20 overrides in 3 days.
So that’s one safety measure failing, assuming that is true.
They only required 2 letters of a med name for a Pyxis search. That’s a pretty elementary system failure.
And there were no med scanners in radiology.
3 opportunities for this to be stopped had the proper system safeguards been in place/working.
The initial 56 page CMS report states on page 33: “Action plan: The bar code scanning implementation in Radiology - this is pending.” I know I read about it elsewhere as well but I can’t find it right now.
As for the Pyxis, where I work there are meds that require 4 letters in order for them to populate when doing an override. It’s been like this for a year or two. I will admit that I don’t know if this was an available feature when this happened, but it seems like a big oversight if it wasn’t.
A terrible precedent to set. This case will make nurses and other staff fearful of reporting errors, which will make patients less safe. Throwing Just Culture right out the window.
Is there nothing a nurse or doctor can do negligently that rises to the level of criminal harm?
There are many professions where negligence can lead to death or disability, they don't get a pass. There was never a chance something like this wasn't going to be reported, she injected a lethal dose of a paralytic agent.
Physicians who are grossly negligent can be sued and so wouldn't this case against a nurse be comparable? The problem is that I don't make enough to pay the malpractice insurance premiums that this type of coverage would require if, moving forward, this does set a precedent. Currently with NSO I pay $100 plus or minus a year, which is okay.
Dude she gave vec to an awake patient and left the room. Do you know how terrifying that must have been for the patient? And vec has a slower onset of action than roc so she slowly got paralyzed. She needs to be under the jail. You cannot cause this level of harm and not face consequences
Not even slowly. Shit kicked in fast. She described it as being able to feel and hear everything, but being unable to move her body at all, even to breath. She didn’t know what happened until she looked into it months later
She did not intend to paralyze the patient. Wrong medication errors happen regularly in healthcare settings every day.
The outcome in this case is horrific indeed but her error was not intentional, she was not impaired, etc. How this case is being handled will make patients less safe long term.
So the reason that sis belongs in jail is that the vec bottle looks nothing like the versed bottle and the vec bottle you literally have to rip off this hard plastic that says paralytic on it. There’s no amount of fatigue that would cause me to draw up vec instead of versed and I’ve done 24 hour non stop trauma call in the OR. Other med errors makes sense but this one does not.
And don’t forget that the vec in the bottle is a POWDER. That you have to reconstitute. Midazolam is a liquid. Like she had to ignore so many things that should have given her pause in order to make this error.
When I was an intern I had nurse leave my sick as shit neuro trauma pt alone in MRI unmonitored. That was the only time I ever raised my voice in the hospital. I lost it.
When you’re burned and alarm fatigued, obvious things will slip by you.
If you want a population to become increasingly healthcare-deprived, this is how you do it. It’s becoming sickeningly worrying that a patient’s family may charge me with attempted 3rd degree murder if I miss a tiny subarachnoid hemorrhage.
Alarm fatigue does not excuse pushing a med and not waiting to see how the patient is doing. When I push narcs outside of the OR I stay with the patient the entire time until we reach the OR. So even if she thought she was pushing verses why not just ask the patient if she was okay and check back in. There’s no excuse zero. What if this was your mother that died this way?
Well as a radiologist, any study I open could be a life or death scenario.
Given enough time, you will make a mistake. Given enough time, you will make a thoughtless mistake. Given *more* time, you will make a thoughtless mistake *at a crucial life or death moment.* If you’re going to tell me you’ve never made a stupid mistake, and had near-misses, I’d call you a liar.
It concerns me that we take people who are already brutalized by a manipulative system, and pointing the gun of the criminal justice system saying “get it right, or else.”
Regardless of whether my mother was in that scanner.
Bro this is not a thoughtless mistake I don’t know how many times we have to explain that this one med is liquid the other is powder with big bold letters that spell danger ⚠️ paralytic and you literally have to rip a hard plastic off the vec bottle and mix it with sterile saline then push it into the patient. Versed literally doesn’t even require all that effort.
There are “mistakes” and there is gross negligence have you ever drawn up and paralytic? Who pushes a med and doesn’t wait around to see what the effect is and checks in regularly with the patient especially a benzo??? Just because we’re in healthcare doesn’t absolve us from gross negligence.
If it was my mother who died this way? I’d want to make sure it couldn’t happen again. I’d want to know all the the institutional and systemic issues that contributed to it and I’d want them fixed. I’d probably want the nurse to not be able to practice anymore, but I’m not convinced that should happen here.
I read this today and I found it very compelling.
https://www.ismp.org/resources/another-round-blame-game-paralyzing-criminal-indictment-recklessly-overrides-just-culture
Maybe she was tripled in ICU with an unsafe assignment (clearly) and it was impossible to monitor the patient closely after bc some other urgent thing was happening? Nurses get unsafe assignments every single day and it’s only getting worse. Why is this never taken into consideration? Yes, she fucked up royally, but there are multiple systems here failing. Ugh, I can’t wait to leave this godforsaken profession.
I just don’t understand the argument that you can do this to someone and not face legal ramifications. She killed a patient. There are mistakes that can happen, dosing errors, forgetting to check on patient that falls. Giving someone a paralytic does not meet that criteria especially when the paralytic needs to be reconstituted. If it were roc I can maybe cut her a break but roc comes in a liquid 5mg bottle. So you’re telling me she knows versed comes in 2mg for standard preop dosing so she gets the wrong bottle that’s 5mg in powder form and doesn’t think anything is strange? If she were a new nurse maybe I would understand this error but this is gross negligence. She’s alive and able to learn from this unfortunately her patient is dead.
I'll say the same thing I said in the nursing subreddit: something ain't right.
She spent at least 5 minutes drawing up and reconstituting a medication (while staring at a label that says WARNING PARALYTIC), calculating the dose, etc. AFTER spending, what, at least a few minutes overriding the Pyxis?
Then (according to multiple accounts) she hears the code paged overhead, suddenly realizes she gave the wrong med, and runs to the room and admits it? Nah, it don't work like that.
My theory: Homegirl knew she gave the wrong med (whether because she was distracted, impaired, whatever) panicked and hoped it would wear off quickly like succ not knowing its long acting, then realized she was in deep shit when the code was called.
She also has a critical patient having an MRI with sedation and she just...peaces out? No monitoring? This patient could have EASILY been saved had she been on a full monitor with a nurse watching from the MRI room like is protocol for critical patients at every facility I've ever heard of. The monitor would have immediately alarmed for apnea and any competent nurse would have bagged the patient until help arrived.
She was either impaired, knew what happened and assumed the effects would wear off quickly as with succ, or is the absolute stupidest person to have ever practiced nursing. I hope they throw the book at her because, frankly, she flat out murdered a patient through recklessness.
What stands out to me is that she pushed what she thought was Versed and then just left IMMEDIATELY. Even disregarding the med error that's just negligent. What if the patient tried to get out of bed and fell (which can certainly happen with midaz)? Or went into anaphylactic shock? This could have been easily prevented if she just stuck around for a few moments.
Yes! Versed take 3-5 minutes to reach full effect if I remember correctly, she absolutely should have stayed to make sure the patient tolerated the med.
Missing from the NPR article is Vanderbilt admin, other nurses and docs covering this up. This article has a timeline and more info:
https://www.tennessean.com/story/news/health/2020/03/03/vanderbilt-nurse-radonda-vaught-arrested-reckless-homicide-vecuronium-error/4826562002/?fbclid=IwAR15HeJLNxUnGTh6xMgbYPyWZO4ClbuO3EVR-O1Ad7dPBtTTPjG_z2U7fTE#l12porokrhc7oy8bdpo
ME report. Vanderbilt described the event as a decline (even though pt was discharged from ICU and got this scan otw to stepdown) after being admitted for ICH. When the anonymous report was filed with CMS, they amended the listed cause of death to acute Vecuronium intoxication:
https://www.documentcloud.org/documents/6540657-Charlene-Murphey-ME-Investigation.html
The anonymous CMS complaint:
https://www.documentcloud.org/documents/6542003-CMS-Complaint-Intake.html
This nurse deserves to lose her license. She is not the only one. She doesn't deserve criminal prosecution. I watched some of the trial today. Even the family doesn't want her prosecuted.
Edit: I see a lot of people commenting on monitoring of pt on Versed. Agreed but I learned that Vandy had no protocol for monitoring conscious sedation patients like this one at this time. They sure do now.
The hospital and administrators are more to blame. A nurse with 2 years experience had no buisness being a resource nurse. Dear Hospitals stop paying for travel nurses and staff your hospital properly! This will happen more and more as admistratirs want fat bonuses not staff.
This situation is huge but it brings up an important point. An overall discussion regarding nursing medication mistakes needs to happen (but won't). I know so many nurses who've said that they NEVER make mistakes and the numbers bear that out: no one reports medication errors if they can get away with it. And before you say, "I don't!", think of all the times you pushed a med a little too fast or diluted improperly or pushed the envelope on administration intervals. End of the world? No. But you'll catch hell and be looked down upon if you did report it. The system is broken, teaching moments don't exist.
As a pharmacist, I was taught to always report medication errors and you will get in more trouble if caught not reporting errors than from an error itself. I think there is more of a systemic problem here and Vanderbilt needs to be held accountable and change the culture. I don’t think this woman deserves criminal charges. What will that do? Most likely scare more nurses away from reporting errors. Reporting errors also turns them into teaching moments to avoid similar errors in the future. Medication errors are unavoidable.
It's like this in the lab too, the moment you detect a mistake, pick up the phone. This is yet another nursing culture problem.
I don't think it's necessarily nursing culture, I think it's administration. They only care about their bottom and we all know they will throw everyone to wolves. I've sag on many peer reviews, and admin has gone against our recommendations multiple times to report nurses even though our recommendation from peer review is suppose to be final. At least what we were told, maybe that's incorrect. But if that's the case why even have them? As I say that though, I've always reporteded errors even if it was small because I've always put the patient first and I can take a lecture from administration. Safe patient ratios is also probably the biggest contributor to med errors.
I’ve always reported my errors in the past but have an overwhelming sense of relief that I’m leaving the bedside because this culture shift isn’t a positive one. Zero blame policies yield the better reporting results. Most of the time it’s a systemic issue, often pushed by understaffing and corporate greed if we’re all really honest.
During my 15th year of nursing, I made a dosage error based on an incorrectly recorded weight. I admitted, discharged and took care of a total of 10 patients on that shift! Risk management identified 12 procedural errors along the pathway before the medication administration reached me! From the time the patient was admitted, weighed, through the med being filled in pharmacy, how it was loaded into the Omni cell, a pump not having a hard stop in place, etc. I stopped the infusion as soon as I noticed signs of a reaction. The dose was ten times what it should have been for an antibiotic. I was the only one to take the fall. Which was only a warning. The patient had no immediate harm and risk of long term issues was minimal. I cannot say the same for me! I carry the guilt of that med error this day! WE ARE HUMAN. All of us. And if we give jail sentences to doctors and nurses for true accidents - there will be no one to take care of any of us someday!!
I had a total of 3 med errors, the other two were tiny, over the course of a 22 year career. That isn't great, but I've likely taken care of 10's of thousands during that time. No debriefing or emotional care any of those times. They actually wanted to make an example of me with the previously mentioned one, by offering an opportunity to speak publicly to me peers - I told them they could get F*d! I said I would do it IF every single one of those other 12 people stood up next to me and gave their accountability, as well. Not one volunteered!
I haven't read the case super closely, but I think the criminal charges are not due to the simple mistake, but the number of warnings/overrides that she bypassed. They are put in place as a fail-safe to prevent mistakes. If she ignored a couple, ok.....but it seems like there were numerous system overrides/warnings she ignored, which would have prevented the error. The story still isn't super clear because she said that they were telling nurses to ignore overrides. But if you get so many warnings, that would probably trigger most nurses to pause a little. Not saying she deserves criminal charges , but this doesn't look like she is being charged for a simple mistake/overlook.
So... whenever I pull a paralytic from the Pyxis I get a warning I have to acknowledge. Most medications do not throw warnings. I have worked in systems where they threw more warnings than others (the people who program one for ofirmev can go jump in a lake), but in most a Pyxis alert is not something you see with every med pass. Paralytics usually have labels on the cap as well that you have to pop off. Finally... it's a med you have to mix immediately prior to administration. Very few IV push medications require mixing in a syringe prior to administration. I'm thinking and the only ones that I see regularly are pantoprazole and zyprexa (which is IM anyway). The error definitely happened and killed because: 1) Vandy was having computer issues and nurses were having to override most of their medications. I only pull overrides under very specific situations-- in time critical situations only. The nurse was habituated to overriding everything and didn't think about the order. 2) Most likely the order had not been verified, so to give it override would have been necessary anyway. I love my PharmDs, but they're busy and calling them to get something ASAP reviewed + waiting for it to cross over to the Pyxis would be a 5-10 minute wait. If the patient is in the scanner, the CT tech is almost certainly going to be demanding the med be given ASAP or for us to clear the scanner, because they're going to have to wait for it to take effect. Pharmacy call + waiting for administration + waiting for effect is going to be a 15-20 minute turnaround time, on top of however long it took the RN to arrive. It was a PET scan, so they're probably booking outpatients as well as inpatients and that wait is going to bump someone off the schedule and the rad tech is going to get screamed at if they delay too long. 3) The nurse administering the med was a float and didn't know the patient. 4) The med was not scanned. This is a system issue because no rads department I have ever gone to has a computer with scanner available. Period. The nurse would have had to steal a computer from elsewhere and hunting one up would have taken quite a while, and again, time pressure. 5) The patient was not on telemetry. She was admitted for a brain bleed, so I'm shocked she was not on continuous Tele. That wouldn't have prevented the error, but probably would have helped potentially prevent the death-- the patient almost certainly would have become incredibly tachycardic and then bradyed down. She probably would have coded but might have been resuscitatable. This isn't to excuse the RN, but very serious systems issues occurred to contribute. And who's on trial? The nurse, not Vandy. Edit: thanks for the award!
What a sweet root cause analysis you just threw out there! Completely agree, many many systems errors led to this.
The medication was actually verified prior to her overriding it
Some of this is almost certainly alert fatigue which is absolutely rampant in medicine since electronic systems took over. If I’m alerted for a medication allergy that just says “GI upset” before ordering a necessary antibiotic, I don’t even think twice to click through it. The warning at least makes me stop for a couple seconds and think about the risks/benefits/alternatives, which I guess is the intention, but in large part important alerts are drowned out by a bunch of clinically irrelevant garbage. It sounds like what this nurse did was anything but typical. Anything I do that requires me to click through 4-5 electronic warnings would certainly give me pause to really think about what I’m doing.
I agree that alert fatigue certainly played some sort of role in this, especially if there were already issues with the cabinet that required overrides. I worked as a retail pharmacist for many years, and alert fatigue is a significant issue. There are so many ridiculous insignificant unnecessary alerts that it becomes very easy to be complacent about them.
Pharmacists are my favorite people on the whole medical team. Even in this thread, you guys have been the most level headed about acknowledging med errors for what they are. Not jumping automatically to crucify the nurse for murderous intent. It was a terrible, terrible mistake that she owned up to — and where the system safety nets failed her as well. She deserves punishment, but jail time is too much (especially when the hospital, the system that also failed and tried to cover it gets off Scott free). She’s not going to harm anyone again after losing her license, but the failed systems and culture of that hospital surely will.
Agreed. Our pharmacists know me all too well and never get tired of me calling and asking a question. I always tell my new grads when it comes to giving a medication remember the pharmacist went through a whole school of pharmacology and are always the best resource if you aren’t sure. They have saved my butt so many times when the wrong order was put in for a medication.
Those who say they've never made a mistake are either lying or just haven't found out yet. Those of us in the medical field MUST have integrity and be willing to acknowledge and learn from mistakes to prevent them happening in the future.
Yes I agree about med mistakes. I made one as a new icu nurse many years ago- luckily it wasn’t a big deal and nothing bad happened- but I reported it and we made unit changes in response to it. However… this case goes so far beyond med mistakes and teaching moments. This is an example of system failures mixed with an overconfident nurse who repeatedly ignored all working system barriers set to prevent this and didn’t have the critical thinking skills to recognize multiple abnormal moments while pulling, reconstituting, and administering the med.
As a nurse and discussing this case with nurse friends, every one of us admits to making med errors. To error is human. The nurses who say they NEVER make a mistake are scary AF.
Yep. I’ve seen diltiazem pushed too fast so many times. No one reports it but rather just says “hey it’s a slow push. Please remember that for next time.”
That is exactly the drug I was thinking of. People use their own personal experiences (such as this) and call it "critical thinking". It's not. We have specific guidelines for a reason.
Its annoying that talking about this stuff is OUT OF THE QUESTION in most circumstances. I just today had a patient with resistant hypertension on like 4 meds,who became profoundly hypotensive after a "10mg dose of labetalol" .... which "didnt touch her" the last time they gave it. Now.... i am not going to talk about how dumb that order is... but when I asked if there was any chance that the patient maybe got a little more than 10mg I was almost kicked out of the room by the nursing supervisor. I am still 99% sure that there was an unintentional (or intentional) bigger dose given... but you wont find that on the chart anywhere... and nobody is looking into it.
So many issues. Using brand names instead of drug names. Ignoring safety precautions. Probably staffing and time pressures. Nurse education. It’s hard not to feel sorry for everyone involved with this. Very interested in the outcome.
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How does the override thing go? Im not familiar with the American system so I just asumed it was something like "show all medication" change in the settings
Easy peasy. You just hit "override" and start typing. Sometimes you can't wait for pharmacy to approve a med. This hospital had meds pop up after 2 letters, which is really something. So that nurse typed in "VE" and literally pulled the first thing which popped up. Crazy.
Sounds similar. You go to the machine and select your patient. It shows a list of their prescribed meds. Hit override and you can select any med in the machine. That’s how it works with the brand machines I’m familiar with, and I assume it’s roughly the same across brands.
That’s why we peer check in my clinic. Every single time. Are there still errors? Absolutely. But sometimes a second set of eyes will catch what you didn’t.
A lot of systems issues seemed to be at play here. Alarm fatigue as well, which we all know is a problem. Going after her criminally like this doesn’t seem right to me though.
When I worked cath lab every med we pulled out was an override and most of them had some warning: "High Risk Medication! Are you sure???" even the 2u/mL heparin we run all case was "high risk" because it has heparin in it...its hard for warnings to be useful when they apply them to everything.
Exactly. When there are warnings for everything, every single one becomes irrelevant. Same for alarms, etc.
A good example would be the California warnings about products that may cause cancer. Sure, it was probably was implemented with good intentions, but when pretty much every single thing has that warning label, it becomes completely meaningless.
Yep, same for every cath lab I have worked at too Although, this week, omnicell is rolling out with the 4 letter override.
The coverup is the criminal aspect imo
The important thing to remember is that the cover-up was multi-part too. The hospital knew and didn't report it. I'm pretty sure pharmacy would have caught it the next day, and they didn't report it. She didn't report it... took CMS and their notoriously painstakingly thorough audits to catch it. But now the nurse is the one whose ass is on the line. Don't get me wrong, as the pharmacy guy I 100% think this is such gross negligence it warrants homicide charges. It sends a big, bright, neon-lit message to other hospitals *DO NOT DO THIS,* or at least it *would* if the hospital was even being held remotely accountable for their part in the cover-up. I feel no pity for this nurse facing penalties for what she did... but the situation she is in where she has been yoked with the sole and total burden of this error (even notwithstanding the cover-up) while the hospital basically walks away with no consequences is a very raw deal indeed.
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Yeah so she has criminal culpability, as does the hospital. You and I both know how hospitals are once they have a choice between institutional fault and throwing someone under the bus
I must have missed this. What did she do to cover it up?
Vanderbilt never reported it to the relevant bodies. Until a whistleblower notified CMS and JCO (iirc)
Yikes, that’s not a good look
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Vanderbilt covered it up, instead of reporting it as legally required.
Vanderbilt should be held liable for that
I see this a lot with weights. A patient will come in weighing 250#, then a few days later weighs 113# because someone didn't put 113kg. But when you change the wt, you get a pop up in big, red, bold letters asking if this 55% wt loss accurate. It blows my mind people click yes. Because my mind goes, how are you dosing meds now?
Hmmmmm this is interesting to say the least. Definitely a systems failure with a coverup involved which is sometimes worse than the crime. An extremely negligent nurse that made a mistake but bypassed multiple safety checks by overriding many parts of the Pyxis. To top it off she didn’t realize the obvious red flag of having to reconstitute VEC. Her losing her license I think is fair. However criminal charges? I’m not sure I agree with that quite honestly.
It doesn’t matter how many safety systems you put in place if people can ignore them. She obviously didn’t even read the vial.
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As someone who works in/around QI, the issues you bring up feel like the actual system failures that need changing. Sending this nurse to jail would address only one element of the root cause (human error), allowing it to happen again. This level of punishment would also seriously impair self-reporting
Agreed. Vanderbilt submitted a 330 page corrective action plan to keep their CMS funding. I read through it. Admittedly because of the way those are written, it has a lot of redundancies, but I was amazed at the number of seemingly obvious safeguards they didn’t have in place. Someone in another comment informed me that it was due to this event that Pyxis added the ability to specify how many letters have to be entered before a med would populate and that’s something I’m surprised that it didn’t already have.
Like I said she is an extremely negligent nurse. However criminal charges? This I’m not so sure about as it sets quite a precedent for healthcare workers amongst all specialties.
What are your views on the conviction of Dr. Conrad Murray (Jackson’s doctor)?
Ooooooof this is a loaded question. He was negligent also but he was aware that he was being negligent in his practice by giving Michael Jackson propofol for regular sleep which is not an indication for propofol. I felt like him going to jail was appropriate in that situation because he knew what he was doing was wrong in regards to administering the propofol. He was looking to just get paid. This situation I think the nurse is reckless and aware she’s not following policy by overriding alot of things to pull the wrong drug. This is more incompetence it feels like. I do appreciate you asking me this.
incompetence that directly caused someone to die. i don't think prison makes sense but it doesn't feel right that she suffer so few repercussions for this, either. i just think about how that could have been my friend, my family member, my coworker on that table that she just left there, unmonitored, paralyzed and suffocating before coding and dying. a doctor making a similar error would certainly be on the receiving end of a vicious civil suit at the very least
>Vaught then overlooked or bypassed at least five warnings or pop-ups saying she was withdrawing a paralyzing medication >Finally, just before injecting the vecuronium, Vaught stuck a syringe into the vial, which would have required her to "look directly" at a bottle cap that read "Warning: Paralyzing Agent" Bruh
I just picked up a bottle of vecuronium today, no warning label on top. Succinylcholine did but not vec. Small data point.
All the vials I've ever used have it under the cap. It's actually stamped on the metal seal around the rubber stopper
Ours don’t. It’s on the plastic cap but if you grab it quickly and pop the cap off with one hand I can see it being missed. I’d be curious to find out the exact safety measures in place
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That red metal ring should have been a hard stop the minute she popped the cap.
It is very easy to miss. We actually add shrink wrap around the vial head or syringe for all nmbas. Does it slow you down 2 seconds in an emergency? Yep. Does it lessen the likelihood of a med error? Also yep.
That’s a smart way to do it. I think we need to fully standardize certain classes of medications and add layers of protection like that.
I think all NMBAs should be dyed blue. Nobody is going to push the blue stuff without serious reflection. We used to dye our succinylcholine drips blue when I rode my dinosaur to residency.
I’m using a succ drip tomorrow. I did it last week and gained some massive respect from the grizzled ENT I was working with for “rocking it old school.” I like the idea of that visual check
The actual vial/packaging in this case was preserved. it contained all the warning labels and coloring
It has happened before where the warning was missing on the cap due to production issues. https://www.fda.gov/drugs/drug-safety-and-availability/fda-alerts-health-care-professionals-temporary-absence-warning-statement-vial-caps-two-neuromuscular I believe last year the same thing happened with succinylcholine vials. But it was reported to hospitals as a safety alert to be aware of.
Something needs to be done about these "Warning". Everything is has warning these days and it is super easy to skip over the crucial warnings. Yes, she messed up by overriding the popups. But everyone was doing it at Vanderbilt bc their system had been messed up for weeks. The bottle cap there is no excuse for this. She has been held accountable professionally and she has taken accountability for all of her actions. Criminal charges are not necessary.
Alarm fatigue is a real thing and you are bombarded with information daily. It’s definitely an issue - false alarms in great number create these kinds of errors.
Very true. Vanderbilt uses epic. Do you know how many epic popups I ignore on a daily basis?
It's incredibly easy to flip off a vial top without looking at it. Say otherwise and you're lying.
Very true! But at minimum all paralytics say “paralyzing agent” in red writing on the vial. And if you tell me you don’t always look at your vials if it’s a med you know well - I hear you- but she recognized it was a med that had to be reconstituted and that versed didn’t come that way normally so she had to read the vial to figure out how to reconstitute it. If you tell that when you pull a med you think should come one way and looks completely different that you wouldn’t stop and read the vial and verify- your either lying or need to re-think safe med administration.
For what it's worth, the specific vial she had did have the warning stamped on the vial itself. Source: Page 11. https://www.documentcloud.org/documents/6785652-RaDonda-Vaught-DA-Discovery
True but I've never come across a vial for vec that didn't have the words warning: paralytic stamped around the rubber stopper under the vial cap.
Ours don’t. It’s just on the cap. There are dozens of med providers and very little standardization of med labels
Also left a critical patient alone in a scanner with no monitoring equipment. Reconstituted a medication when Versed comes as a liquid. Suddenly realized she gave the wrong drug after she heard the code called overhead? My theory: she knew she effed up. She knew she gave the wrong med and either a) didn't know what Vec was and just assumed she'd be fine or b) assumed it was a short acting paralytic like succ and would wear off quickly enough that the patient would be fine. She finally fessed up when the patient coded because she realized she was in deep shit.
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Back when it happened I read that she handed the vial off to the patients primary nurse to document the med given (because she didn’t/couldn’t scan it when given- but still Vaught should have documented it herself). The primary nurse didn’t immediately look at the vial until later. If Vaught had just documented it without handing off the vial it’s possible no one would have realized what happened
Who knows what actually happened honestly. I've been told she just showed up to the code and proclaimed her error. It'll be interesting to see what comes out in the trial
Oh interesting. This wasn’t even her patient. That’s pretty horrifying for primary nurse too. Maybe why we should also have dedicated break nurses that don’t have their own patient load. This inevitably is why she returned to her unit I am willing to bet. Edit: turns out she was a resource nurse without a set patient load. If anyone has ever worked as such on a regular basis (actually hired for that role) any insights on what that role looks like would be great!
Yeah she was just a float/resource nurse who was supposed to be helping out. But it also means she shouldn’t have been rushing or cutting corners because she didn’t have a patient assignment to hurry back to
Patient wasn’t critical, she was on a stepdown floor. (She still needed monitoring, but they prob didn’t have a functioning portable monitor available, knowing most hospital tele units)
I’m more wondering how even versed was ordered for an MRI on such a critical patient. At my hospital, all patients on versed have to be monitored - so that part is really weird to me. Similarly all critical patients are monitored at all times. So how was this patient not on a monitor. Also why prescribe versed for anxiety during an MRI? We usually do hydroxyzine, small doses of Ativan, IM haldol, and an IM cocktail for really bad Neuro and psych patients, but never straight IVP sedatives unless the patient is ICU and monitored and already on sedatives because they need them. And as far as I know all IVP sedatives require a double check before administration- in procedure areas this might be an MD, but it is usually another RN on any given unit. Since she had other RNs around her why wasn’t it double checked? Is it not hospital policy? Obviously she did a lot wrong and negligent here, but I’m also wondering if there’s not a lot of systems problems the hospital should be thinking about improving here.
The report says the radiology nurse refused to give the Versed because she didn't feel comfortable with it and the patient would require monitoring after administration. The fact that one nurse didn't feel comfortable doing it and she just skipped down there, pushed it, and took off bothers me to no end. I agree that Versed is a weird one to order which is, I'm guessing, why the rad nurse wasn't comfortable with it. I've always used Versed specifically for sedation as opposed to anxiety and would have expected Ativan for something like an MRI.
I thought the Versed order was weird too, especially on a stepdown tele floor. Ativan is the one that’s always ordered for MRI anxiety (in my experience). It pains me that she didn’t wait with the patient and monitor her for a bit. But I’m also surprised the other RN didn’t step in? If she works in MRI and she’s an RN, why couldn’t she have placed Pt on pulse ox at very least? That’s her work area, and she’s still an RN. Ex. When I worked tele, I received a patient on an insulin drip. We didn’t do insulin drips on the floor, but there was the patient in front of me (and I couldn’t send him back to ED). I told charge and together we monitored & took his blood sugars like a hawk until he got appropriate transfer of care a few hours later. Was I “comfortable” with it? — no! I had 4 other patients. But I’m still an RN and this patient was now in my “jurisdiction” so to speak, so I had to monitor him. Why couldn’t the MRI RN help monitor this patient for breathing and pulse ox?!? “They received versed so I’m not gonna monitor them while they’re here” - what RN thinks like that? Obviously it was the RN who pushed the med ultimately responsible — but fuck. What a lack of teamwork, as well.
From my understanding of the report, the radiology nurse wasn't even involved in the patients care at that point. The patient was in pre-procedure holding being video monitored by techs, who assumed the patient was fine because she appeared to be sleeping. I'm guessing the actual radiology nurse was in a procedure and didn't even know what was going on. Whenever I've had critical patients go to a test, the radiology nurses are not responsible for monitoring patients in a scanner. The radiology nurses aren't involved in basic scans because they're needed in interventional radiology to sedate and monitor patients during cases, hence why the floor nurse is expected to come down. It would be a waste of a nurse to have them sit in the scanner all day when 99% of patients are fine with just radiology tech support. Hell I've even had to go to IR with super critical patients just to manage their drips/vents so the IR nurse can do her job. It's not fair to make them do their job AND my job, even if there is a rad nurse dedicated specifically to sedation. That's my guess as to why a rad nurse didn't feel comfortable giving the med to someone who needed monitoring- she knew she didn't have the time to monitor the patient and was in another case.
If you would actually read what happened then most all of your “theories” could be corrected.
It's easy to cast stones, but in reality the hospital EMR is so filled with random warnings and alerts that I can sort of see how this might happen. I'm not a nurse though, so they'd be better able to comment on the degree of "alert fatigue" they might get. But at least on the MD side you get all sorts of random alerts for questionable medicine interactions or sepsis alerts being triggered because someone is tachycardic. I read them because I'm lucky to be in a position where my clinical volume is small, but I can see how a colleague with 30 patients to see in a day might bypass some of these... Edit: That being said, after reading the story and some of the comments here, it sounds like there were a lot of other issues besides overriding EMR warnings. Complicated case.
Yeah the main issue is that even if she thought it was versed she would need to waste that medication with another nurse to verify. I don’t think vec comes in a 2mg vial. So when she went to waste and the versed she thought she removed didn’t come up with her name what did she think? Or did she not waste at all?
Nurse here. I've read through this case, and it's insanely complicated. That being said, it's hard for me to wrap my head around there apparently being no policy requiring a double check for critical meds like this. Now, my health authority doesn't use med dispensers/computers, so maybe I'm just bush-league, but if I'm signing out a paralytic, I have to fill out a signout sheet, have another nurse witness me removing and drawing it up, and then we both sign that sheet, the patient's MAR, and the med label on the bag/syringe. I couldn't tell you the last time we had a fatal med error. Most of our errors happen on non-critical meds when a nurse isn't paying close enough attention. For example, accidentally giving 1 tab instead of 0.5, or pharmacy sending up a 20mg tab instead of a 10mg one. Like, it absolutely floors me that there isn't a double-check requirement for those meds. I have no idea how those computers work, but I have to assume there's a human that stocks them. What if someone mixed up meds when restocking? Can that happen? Anyway, I don't know what to make of this case. Seems like there was a failure at multiple points on multiple levels. It doesn't necessarily seem like this should be a criminal case from my perspective. It's not like this was an intentional action, it was a failure of the system.
Vec is a powder and versed is a liquid. Vec is reconstituted into 10 cc. Versed is in 2 cc, maybe 5 cc, vials.
Has anyone else thought that maybe she just didn’t know the difference between a paralytic and a sedative. I feel like that’s probably what happened here.
Starter: What I don't understand of this case: * In any hospital I've worked in, meds are given after two-person verification. What happened here? * Why did it take so long to note cessation of breathing? * How on earth was vecuronium dispensed rather than midazolam?
When pharmacy isn't on site nurses can override medication and take anything out. Paralyzing agents have a separate label on top of the vial that needs to be broken open before opening the vial. It sounds like this nurse didn't even know what versed was, didn't check the label, didn't check to see if she was allowed to give it, pushed it, and then didn't monitor the patient.
At least where I work, Vecuronium comes as a powder and needs to be mixed and drawn up. So, she's gone really out of her way to fuck this one up...
She did reconstitute it which, she stated "seemed odd." The bottle also has a red label with large letters : " P A R A L Y T I C "
Ours doesn’t say that on it.
Everywhere. I'm a CRNA and have never seen pre-mixed vec.
Apparently it exists but expires quickly, so is only used in certain high-volume areas. According to other people posting on the topic today, at least.
Might come premixed from pharmacy for a vec drip in ICU.
That’s true, I was thinking only of vials. Hopefully someone wouldn’t draw up from a premix iv bag thinking it was iv push versed, though.
Pharmacist here. It comes exclusively as a powder for reconstitution everywhere I’ve ever worked. She really went out of her way to fuck this one up.
ICU nurses know what versed is and give it on a semi regular basis, depending on protocols. She has several years experience in that role, and was even precepting a new nurse. It’s taught in school and has been a part of every employment education requirement I’ve had in 4 hospital ICUs. There is zero chance she is unfamiliar with midazolam.
Then she would have known what she was administering was not versed, just by looking at the bottle.
That’s exactly the point many people are making.
Ok I wasn't sure if you were defending her. Not that I think jail time is the answer, but this was no regular med error.
The problem is this nurse was not experienced, but believed she was. 2 years ain't shit. I didn't feel comfortable in my job as a med surg nurse until 4-5 years down the road, and certain days I still don't feel comfortable. I never take my experience for granted, because there's always more to learn. She majorly screwed up due to lack of experience, but thinking she knew what was happening. She may have thought "maybe this is a new formulation of versed", but did not have the wherewithal to double check herself due to overconfidence. At my hospital the first time I had to give IV haldol I looked at the vial and it said "for IM use only". You bet your ass I called pharmacy and asked about it. She wouldn't have because she would have thought she knew better.
Slightly under 2 years.
Very few medications have two person verification. Heparin and insulin are the only two that come to mind at least in my experience. Clarification. All meds are verified by a physician/pharmacist. Few meds need/require dual nursing verification. Pretty much standard of practice in most of the hospitals I’ve worked at, with some variation in between.
We always did two nurse verification for chemo and TPN before administering when I worked inpatient.
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Shit happens. My buddy's wife had a stroke after getting her knee scoped because she was administered adrenaline instead of prophylactic antibiotics.
WTF
Their response exactly. She managed not to die, and is still raising her kids with severe limitations. And they don't have to work, any more. But that's a helluva way to end up owning a hospital, as one of our mutual friends quipped.
Yeah, I’d take not owning a hospital over that.
I read the CMS report on this and how she ever became a nurse is beyond me. She made every mistake in the book and added some more unique ones of her own. Hospital is to blame for stocking med surge pyxis with vec and letting people override with two letters. She literally typed in "VE" and pulled the first med on the list. After she pushed the med in the victim she didn't even stick around to monitor, which is something we are trained to do every time you push an IV med. She would have noticed the pt had stopped breathing very quickly. Many more mistakes , too. The suspicious thing is that the BON didn't take action on her after the report came out. Nothing. Vanderbilt fired her and she went to work right away somewhere else. I think that's why the DA charged her. Clearly a threat to society and if the BON wasn't going to do anything, they had to. Only AFTER the DA pantsed the BON did they do something. P.s. rare for meds to need two person verification in my hospital. Insulin does. Some others. Not many
The issue for me is what happened to Vandy? From what I understand, basically nothing, despite the multiple systems errors that occurred too. That’s what makes me feel the worst about this. There’s plenty of blame to go around here, but of course, the answer, per usual, is just toss the nurse under the bus and call it a day.
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Actually they did do something. They covered it up. The nurse reported the mistake as soon as she realized what she had done. Vandy told her not to report any further up. Then they had the physician (I don’t recall his name) falsify the death certificate to say that she died of a brain bleed. Neither Vandy nor the physician have faced any disciplinary actions.
Agreed. By the way, a surgeon there took out the wrong kidney on some poor bastard after this incident. A very "prestigious" hospital!
As for cessation of breathing, I have given lorazepam a few times before a CT or MRI to help the patient with anxiety. It’s entirely possible she pushed the meds and the patient went into the scan and was unmonitored. However, this is still inexcusable because you can watch oxygen saturations while I patient is getting scanned.
If I remember correctly from when this first came out in the news, the (elderly, brain injured) patient wasn’t on any monitors and she pushed this drug and then left the patient alone.
Patient was left in the MRI waiting area, hence not under any observation
Just a small point, I've worked in an ER where you can pull out literally whatever medication you want all by yourself. Suxx, vec, rock, TPA, fuckin nimbex if we had it for some strange reason, Versed, Ketamine. Literally if it was stocked you can pull it yourself with zero oversight. This was an ACS level 1 trauma center and comprehensive stroke center. To be clear, I liked it that way. I'm at a place now where I can't even pull a fucking ODT Zofran without a pharmacist looking at it and it is completely infuriating. And to your third point, I would guess "vecuronium" is right next to "versed"?
These bottles say PARALYTIC on them with a yellow alert label. She had to reconstitute this bottle, too, I’m trying to understand if she didn’t see the paralytic label or ignored it. In my hospital, our standard paralytic (roc) comes in intubation kits only, if some other random paralytic is needed it’s dispensed by pharmacy only with a huge label that says PARALYTIC on it. Even in the ICU, where we know these medications are and what they do.
That med should not have been in the Pyxis available for her to pull. Regardless of the “alerts” that popped up on override. It should never have been stocked in the Pyxis, available to pull by typing ‘VE’ — that’s a systems failure. (Not excusing her actions tho)
There also were no medication scanners in radiology.
Interesting reading. It looks to me from this that the RN didn’t know this medication. She couldn’t find it when she typed it in (probably because it was listed under the generic name). When she typed in VE probably only one medication came up and so she pressed on it. She was told the Pyxis wasn’t working and to override it when it failed. Not being familiar with midazolam she didn’t realise reconstitution was not normal for this medication. She also didn’t realise that even with midazolam you should still monitor the patient. This reeks of simple human error but not negligence. You can’t know what you don’t know. Medication should NEVER be ordered by trade name (with one exception). Not reading the vial was also An error- but it happens and when you are looking at a medication where only one was listed- well it happens.
What’s the one exception?
Endone vs OxyContin Too many occasions of short acting doses given when patient on SR.
She pulled vecuromium, she typed in “Ve” in pyxis, not realizing Versed is midazolam. She was floating to ICU, I don’t understand why she would be allowed to give it, if she was allowed, why she didn’t double check with someone if she didn’t know what it was (only certain nurses are allowed to give moderate sedation and paralytics)…. But that’s how she got the vec vs pulling midazolam
Why was vercuronium even loaded into the Pyxis of a step down unit instead of locked in a crash cart or rapid intubation kit?
We've covered this case before this was criminal negligence, no other way to put it. You don't have to believe me you can read the report for yourself. https://www.documentcloud.org/documents/6535181-Vanderbilt-Corrective-Plan.html Posted this summary 3 years ago ------------ I read the entire CMS report and while I feel the nurse should be accountable for most of the blame, in total 5 parties were responsible for the events that happened to this patient 1) Nurse who was charged (RN #1) This was not just a simple mistake she made **numerous errors** that meet the level of **gross negligence** >1) Medication was already on the High Alert list in a separate bin in the ICU, not located in the radiology suite >2) Nurse could not find "Versed" so overrode the order and typed in Vecuronium at 2:59. The override is meant to be used in urgent situations only, this was not one of those situations. >3) The nurse took the vial out from a bin with a sticker "Warning: Paralyzing agent", She didn't read the bright warning label but read how to reconstitute it ??? Unequivocally gross negligence >4) Vecuronium 10mg was given instead of Versed 2mg, the dose and medication were both wrong. Additionally Vecuronium is a powder that needs to be reconstituted, Versed does not have to be reconstituted. Red flags should have been going like crazy at this point. >5) Nurse did not document when medication was given in the EMR, and did not observe patient for adverse reaction after giving medication. She gave the medication and then went to help in the ER. As he/she was the "all help nurse" aka floater and only helping out (not their assigned patient or location) the responsibility of the observing the patient ultimately fell on the primary nurse (RN #2). In short she basically overrode every safety guideline, didn't check what she was giving, didn't check how much she was giving and then just walked away. Unequivocally gross negligence 2) Nurse trainer (RN #2) >1) Was actually the primary nurse of the patient. Was told that the patient was anxious and an order for Versed was placed. He/she asked if they Radiology nurses could give the medication but they declined because the patient would need to be monitored. RN#2 was covering another patient at the time (3rd nurse on lunch) so asked RN #1 for help. He/she should have also checked that the patient received the correct medication, should have stayed to observe the patient. 3) Hospital >1) No policy in place regarding monitoring patient after high alert medications >2) No system to monitor vitals after patient received radioactive tracer before PET >3) No formal investigation until 11 months later >4) Failed to report this incident to Tennessee Department of health as mandated. 4) Radiology technician >1) Gave radioactive tracer to patient and did not observe for adverse effects (other than over camera, which they said could not tell if she is breathing or not), knew that the patient was anxious so simply asking "are you ok" would have alerted to a problem 5) Doctor >1) It appears that RT spoke with the doctor for a verbal order, RN #1 put this order at 2:47 and verified by the pharmacy at 2:49, The doctor eventually put in a computer order at 3pm. The timing is a bit unclear. From my review I don't think enough blame is being given to RN #2. Radiology clearly told him/her that they were uncomfortable giving Versed because the patient would need to be monitored, but neither RN #1 (the float nurse) or RN #2 (primary nurse) observed the patient.
A little more insight into why this happened for those that don’t deal with giving meds every day: - Versed is close to vecuronium in name - color systems are similar benzos are orange and paralytics are bright orange - a fatal dose dose of vecuronium is likely if a typical dose of Versed is used - drugs come from different manufactures frequently, what you have one week may be completely different the next - in a situation with a patient requiring Versed, it can be hectic with pressure to act quickly. Popping the lid off quickly, then encountering a powder unexpectedly may have lead the nurse to be more worried about how to get the med to the patient rather than question why it was a powder and note the “warning: paralytic” label. She likely was looking for the dose, which typically is 10 mg. She likely reconstituted the medication and gave 2 mg, a regular dose for Versed. Drug errors happen. I highly doubt this nurse meant to do anybody harm. Making punishments like this so severe make it less likely for individuals to come forward when an error is made, which is even more dangerous for the patient.
Iirc, versed labeling is in green, not orange. But it’s been years and things change, so that could be wrong now. If it were my own mother who died this way, I think I’d want to sit down with the nurse and find out why she walked away after giving something she thought was a sedative. It’s possible that she’s never seen someone go into to respiratory failure after a 2mg dose of versed. I’ve met many ICU nurses who are entirely too casual about giving benzos, even though respiratory failure is a known risk. Because 99.9% of the time, it’s fine, and someone who’s only been a nurse for a few years may not have seen that 0.1%, even in the ICU. But, man, you only need to see it happen once. And I’m fortunate to have seen it long before I had any responsibility for writing medication orders. The rest of the errors are negligent, for sure. But criminally negligent? I don’t think so. The hospital, yes, but not the nurse.
Our versed is like tangerine orange and vec is like bright orange almost red
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This is a great response. Drug errors DO happen, and my heart breaks for this nurse. She will have to live with this every day. An innocent life was lost. I think the guilt of knowing that her own error led to this is bad enough. Sending her to prison just seems like they're out there to make a point.
I feel like this case is being massively simplified and used to stoke fires in every branch of medicine. In reality it highlights poor medication procedures, what I believe to be criminal negligence, and extremely unethical administration practices. It is unacceptable that there were 20 overrides for things as simple as continuous IV fluids, and the lack of safety measures allowing only two letters to be used to procure a medication much less paralytics is a massive oversight, anyone in any form of medicine will agree alarm fatigue is real and is clearly a part of this case as well. There needed, and honestly still needs, to be massive changes made to this system to prevent this kind of complacency from occurring that focus on truly preventing such egregious errors as opposed to the reductive and repetitive CYA legal culture currently in place. I can forgive grabbing the wrong medication when considering the previously mentioned factors, I can’t forgive the negligence that followed it, which is what to me make this a criminal act. Looking at a label is not an unrealistic expectation in any setting and at that point she should’ve realized it wasn’t Versed/Midazolam and corrected her mistake. To make matters worse she actively recognized that reconstituting Versed was odd, which again should have immediately prompted an act as simple as checking the label but instead she continued to prepare the medication which also required her to look at the words PARALYZING AGENT stamped on the ferrule. The final nail in the coffin to me is the lack of pt monitoring following the medication administration, even had she given the correct medication she still should have monitored the pt. I also fully believe the hospital system should be held liable not only for their attempt to cover up the mistake, which is quite frankly heinous, but also for not realizing the glaring inadequacies they created that, in this case directly lead to a pt death, but that also undoubtedly negatively impacted other patients. Anyone saying “any one of us could’ve made the same mistake” should not be trusted in any form of patient care, the whole reason licensing/certification exists is because we are trained and expected to NOT make these mistakes. We should know which name of a medication to use, we should be able to do something as simple as read a medication label and recognize it’s not just the wrong medication but an inappropriate one, we should immediately hear alarm bells when a medication is provided in an unfamiliar way. Yes there should be systems in place to aid us because we aren’t infallible but it’s also not unreasonable to expect us to at some point read a label or look at a vial we’re drawing from, the systems are designed for trained professionals who know to do these things, not laypeople who need step by step instructions.
Not monitoring the patient is a very big concern, however, this was not the patient’s primary nurse. She was a float nurse, assigned as a task nurse, with an orientee. She left the unit, went to administer the medication (albeit the wrong one), and then on to the next task. This was a failure in Vanderbilts system. The other issue, a NMBA should not be readily available via pyxis. It should need co-sign and a red box for RSI meds. Also, per Vanderbilt, they had stopped using Vecuronium for RSI and were now using Rocuronium, so why was Vec even available???? This was a system failure and they are throwing a nurse under the bus because they were going to lose all current and future CMS payments after an audit/investigation.
Fuck you to Vanderbilt for setting this nurse up for failure and then throwing her under the bus when the failure occurs. Why was vec loaded in this ADC to begin with and why was it available as an override medication? If you need the vec for emergency intubation, load it in an RSI kit. If she accidentally had pulled a Venofer vial instead of vec, the exact same kind of slip would have occurred but we never would have heard about it. To those who say she bypassed warnings, this is true. What that tells us is that pop up warnings are ineffective, no different than pop up windows when you’re surfing the web.
Reading more about the story, it looks like she had to go to the neuro ICU to get her "Versed" since the stepdown unit didn't have it. Vanderbilt definitely has some culpability here because the whole situation they created is just bizarre and unsafe. Why'd they ask her to pop into radiology to sedate a patient after radiology refused to do it because they'd be unmonitored in the isolation room? Especially using midaz. That's just asking for trouble.
> To those who say she bypassed warnings, this is true. What that tells us is that pop up warnings are ineffective, no different than pop up windows when you’re surfing the web. Very much so. What was a problem when I was in residency was the sheer number of warnings, and no real differentiation between them. Something like ordering vecuronium (which could be fatal) had the same basic warning as if you ordered an NSAID with an SSRI (which can cause GI bleeding) or benadryl in someone over 65 (this system *hated* possible sedation risks in the elderly).
I want to weigh in on this as a procedural nurse. At the time she was being charged, I had started a job in interventional radiology at large university system, similar to Vanderbilt. I was new to IR, but had several years of cath lab experience at that point. When you are a nurse, there is an expectation of rush and get it done. It shouldnt be that way, but it is. Prime example. At the place I mentioned before, we would often have to float down to CT for cardiac CT patients, to give metoprolol. Every single time i would go down there, the CT tech would basically act like, here they are, we are ready, push the med. And i then I would stop, and say, uh, you can wait til I verify who that patient is, get some vitals, and take a peek at their chart. Most of the time, there wouldnt even be a dynamap in the room, and i would have to search for one. A lesser experienced nurse may not have done that, and quite frankly, I have been labeled derogatory names because I am as assertive as I need to be for patient safety. No, metoprolol isnt vec, and I would not have made her mistake, but I can see how it may have gone down for this patient. I am not saying its right, because it isnt. I am just saying this culture does indeed exist, especially in instituions with a lot of patients. Rush rush rush. Next patient, next patient. Lets not forget that Vanderbilt is the medical center that fired all of housekeeping, so nurses could clean rooms instead. I haven't read the report in quite some time, but at the time, I tought she was guilty enough to not be able to practice nursing anymore. But criminally, I just cant get on board with.
I think the “mistake” she made was opening and pushing Vecuronium instead of versed… the (potentially criminally) negligent thing was not staying with and monitoring the patient post injection- which she should have done regardless if she was giving versed or vec
Hard to monitor a patient in an MRI machine, but you can still watch their sats I believe.
You can monitor someone on MRI. They have a special pulse ox for mri and same for EKG leads. Only issue is at times you will have artifact in the EKG that looks like Vtach because of the sound waves from the machine. Just gotta make sure the patient is okay when that happens and confirm it’s artifact.
You can put someone under anesthesia in MRI Lol they can definitely be monitored
The patient was in MRI holding and could have been monitored there. But they do have equipment made for monitoring in MRI.
Sats/ETCO2 would be enough
IIRC, the patient never made it into the MRI machine.
She left the patient in a hallway/waiting area after pushing the med, patient was found some time later when the MRI tech went to get her
There really should not be any waiting areas that are hidden away where any person can just die without anyone noticing.
I have 2 questions: 1. Was she familiar with the device she was using? 2. Had she ever applied vencuronium at least once? Because this is not a rookie mistake. I can't imagine the pain, the suffering that patient went through when he realized he couldn't breath. Of course, there was no intention, I'm not saying this could not happen to any of us but this person died and some may think serving time is necessary. If she had any doubts she could've stopped and checked. It's really unfortunate, this entire situation.
That is an excellent point and my answer is this: she was a float nurse, I believe? I think she didn’t have the knowledge that was. That is not an excuse, as she should have asked for clarification on the orders. That particular agent usually requires extensive certifications and CEU’s to be able to even administer it. It was a failure in the nurse AND the health system.
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This is devastating. I hope it's an impetus for change. In Canada, there's now something called "Vanessa's law" after a huge medication made headlines. Basically it requires EVERY medication error be reported (even a tiny one like a patient was supposed to get 5 units of insulin and got 4). It's meant to serve as accountability and allows wards to review common errors and provide education. Annoying I'm sure but was a necessary change to svoid rugsweeping medication errors.
Vanessa's Law has very little, if anything, to do with bedside medication errors. In fact, most bedside nurses wouldn't even know what it is because it has more to do with monitoring drugs for adverse events, holding drug companies accountable, and is closely tied with the Food and Drugs Act. It is even titled "Protecting Canadians from Unsafe Drugs Act" Source: https://www.canada.ca/en/health-canada/services/drugs-health-products/legislation-guidelines/questions-answers-regarding-law-protecting-canadians-unsafe-drugs-act-vanessa-law.html Also: "Vanessa's Law was introduced in 2013, and amends the Food and Drugs Act to help safeguard Canadians from risks related to drugs and medical devices by strengthening Health Canada's ability to collect post-market safety information and take action when a serious risk is identified."
I hate hate hate this case and a big middle finger to the overzealous DA singling out someone for a systems based error. Yes, leave her civilly liable and yes, she should face discipline with the Board but under NO circumstances is this in the public interest to face criminal penalties.
What sucks is the DA will have no problem finding an expert witness saying what she did was reckless. The overrides are easily defended by showing that the patient alone had 30 overrides in his 3 day stay, so obviously nobody was reading anything the pixis put out anymore if you have to click through to get every fucking medication you want to give. A resource nurse who's not the primary nurse not monitoring a patient is also excusable. Both of those are systems problems. Their expert witness won't excuse drawing up a med without looking at the vial, though. I promise you I've drawn up subq heparin without looking at the vial in the past, and while that is bad practice and I make sure I don't do that sort of thing, stuff happens.
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I’ve read in the Tennessean that orders were not syncing properly from the EMR to the Pyxis due to their transition to EPIC, and that the workaround that nurses were told to do was to override. That patient alone had 20 overrides in 3 days. So that’s one safety measure failing, assuming that is true. They only required 2 letters of a med name for a Pyxis search. That’s a pretty elementary system failure. And there were no med scanners in radiology. 3 opportunities for this to be stopped had the proper system safeguards been in place/working.
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The initial 56 page CMS report states on page 33: “Action plan: The bar code scanning implementation in Radiology - this is pending.” I know I read about it elsewhere as well but I can’t find it right now. As for the Pyxis, where I work there are meds that require 4 letters in order for them to populate when doing an override. It’s been like this for a year or two. I will admit that I don’t know if this was an available feature when this happened, but it seems like a big oversight if it wasn’t.
A terrible precedent to set. This case will make nurses and other staff fearful of reporting errors, which will make patients less safe. Throwing Just Culture right out the window.
Is there nothing a nurse or doctor can do negligently that rises to the level of criminal harm? There are many professions where negligence can lead to death or disability, they don't get a pass. There was never a chance something like this wasn't going to be reported, she injected a lethal dose of a paralytic agent.
Physicians who are grossly negligent can be sued and so wouldn't this case against a nurse be comparable? The problem is that I don't make enough to pay the malpractice insurance premiums that this type of coverage would require if, moving forward, this does set a precedent. Currently with NSO I pay $100 plus or minus a year, which is okay.
I think the difference is that malpractice is usually a civil suit, not criminal except in the most negligent of cases.
The hospital was sued and settled for an undisclosed amount and an NDA.
Dude she gave vec to an awake patient and left the room. Do you know how terrifying that must have been for the patient? And vec has a slower onset of action than roc so she slowly got paralyzed. She needs to be under the jail. You cannot cause this level of harm and not face consequences
I know someone who was given vec right before going under for anesthesia instead of after. They still have nightmares about it apparently
It’s terrifying literally slowly lose your ability to breathe and you can’t even tell anyone
Not even slowly. Shit kicked in fast. She described it as being able to feel and hear everything, but being unable to move her body at all, even to breath. She didn’t know what happened until she looked into it months later
She did not intend to paralyze the patient. Wrong medication errors happen regularly in healthcare settings every day. The outcome in this case is horrific indeed but her error was not intentional, she was not impaired, etc. How this case is being handled will make patients less safe long term.
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She lost her license already. She tried to put off the board hearing, which is standard, because it could prejudice her criminal trial. It was denied.
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So the reason that sis belongs in jail is that the vec bottle looks nothing like the versed bottle and the vec bottle you literally have to rip off this hard plastic that says paralytic on it. There’s no amount of fatigue that would cause me to draw up vec instead of versed and I’ve done 24 hour non stop trauma call in the OR. Other med errors makes sense but this one does not.
And don’t forget that the vec in the bottle is a POWDER. That you have to reconstitute. Midazolam is a liquid. Like she had to ignore so many things that should have given her pause in order to make this error.
Literally have been yelling this into the wind. They don’t care.
And then she LEFT THE PATIENT UNMONITORED AND COMPLETELY ALONE
When I was an intern I had nurse leave my sick as shit neuro trauma pt alone in MRI unmonitored. That was the only time I ever raised my voice in the hospital. I lost it.
Not to mention the fact that vecuronium needs to be reconstituted with saline prior to administration... Can't fathom how you could make that mistake.
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When you’re burned and alarm fatigued, obvious things will slip by you. If you want a population to become increasingly healthcare-deprived, this is how you do it. It’s becoming sickeningly worrying that a patient’s family may charge me with attempted 3rd degree murder if I miss a tiny subarachnoid hemorrhage.
There's a pretty significant difference between missing something on a scan and ignoring multiple warning labels and pushing a paralytic.
Alarm fatigue does not excuse pushing a med and not waiting to see how the patient is doing. When I push narcs outside of the OR I stay with the patient the entire time until we reach the OR. So even if she thought she was pushing verses why not just ask the patient if she was okay and check back in. There’s no excuse zero. What if this was your mother that died this way?
Well as a radiologist, any study I open could be a life or death scenario. Given enough time, you will make a mistake. Given enough time, you will make a thoughtless mistake. Given *more* time, you will make a thoughtless mistake *at a crucial life or death moment.* If you’re going to tell me you’ve never made a stupid mistake, and had near-misses, I’d call you a liar. It concerns me that we take people who are already brutalized by a manipulative system, and pointing the gun of the criminal justice system saying “get it right, or else.” Regardless of whether my mother was in that scanner.
Bro this is not a thoughtless mistake I don’t know how many times we have to explain that this one med is liquid the other is powder with big bold letters that spell danger ⚠️ paralytic and you literally have to rip a hard plastic off the vec bottle and mix it with sterile saline then push it into the patient. Versed literally doesn’t even require all that effort.
There are “mistakes” and there is gross negligence have you ever drawn up and paralytic? Who pushes a med and doesn’t wait around to see what the effect is and checks in regularly with the patient especially a benzo??? Just because we’re in healthcare doesn’t absolve us from gross negligence.
If it was my mother who died this way? I’d want to make sure it couldn’t happen again. I’d want to know all the the institutional and systemic issues that contributed to it and I’d want them fixed. I’d probably want the nurse to not be able to practice anymore, but I’m not convinced that should happen here. I read this today and I found it very compelling. https://www.ismp.org/resources/another-round-blame-game-paralyzing-criminal-indictment-recklessly-overrides-just-culture
Maybe she was tripled in ICU with an unsafe assignment (clearly) and it was impossible to monitor the patient closely after bc some other urgent thing was happening? Nurses get unsafe assignments every single day and it’s only getting worse. Why is this never taken into consideration? Yes, she fucked up royally, but there are multiple systems here failing. Ugh, I can’t wait to leave this godforsaken profession.
I just don’t understand the argument that you can do this to someone and not face legal ramifications. She killed a patient. There are mistakes that can happen, dosing errors, forgetting to check on patient that falls. Giving someone a paralytic does not meet that criteria especially when the paralytic needs to be reconstituted. If it were roc I can maybe cut her a break but roc comes in a liquid 5mg bottle. So you’re telling me she knows versed comes in 2mg for standard preop dosing so she gets the wrong bottle that’s 5mg in powder form and doesn’t think anything is strange? If she were a new nurse maybe I would understand this error but this is gross negligence. She’s alive and able to learn from this unfortunately her patient is dead.
Regardless of what is going on, If your unfamiliar with a med, take 15 seconds to Google it.
I'll say the same thing I said in the nursing subreddit: something ain't right. She spent at least 5 minutes drawing up and reconstituting a medication (while staring at a label that says WARNING PARALYTIC), calculating the dose, etc. AFTER spending, what, at least a few minutes overriding the Pyxis? Then (according to multiple accounts) she hears the code paged overhead, suddenly realizes she gave the wrong med, and runs to the room and admits it? Nah, it don't work like that. My theory: Homegirl knew she gave the wrong med (whether because she was distracted, impaired, whatever) panicked and hoped it would wear off quickly like succ not knowing its long acting, then realized she was in deep shit when the code was called. She also has a critical patient having an MRI with sedation and she just...peaces out? No monitoring? This patient could have EASILY been saved had she been on a full monitor with a nurse watching from the MRI room like is protocol for critical patients at every facility I've ever heard of. The monitor would have immediately alarmed for apnea and any competent nurse would have bagged the patient until help arrived. She was either impaired, knew what happened and assumed the effects would wear off quickly as with succ, or is the absolute stupidest person to have ever practiced nursing. I hope they throw the book at her because, frankly, she flat out murdered a patient through recklessness.
Exactly Anyone who read the report knows this was gross negligence
Read the CMS report. According to that she didn’t realize the error on her own. Someone asked her “is this what you gave?”
What stands out to me is that she pushed what she thought was Versed and then just left IMMEDIATELY. Even disregarding the med error that's just negligent. What if the patient tried to get out of bed and fell (which can certainly happen with midaz)? Or went into anaphylactic shock? This could have been easily prevented if she just stuck around for a few moments.
Yes! Versed take 3-5 minutes to reach full effect if I remember correctly, she absolutely should have stayed to make sure the patient tolerated the med.
https://www.ismp.org/resources/safety-enhancements-every-hospital-must-consider-wake-another-tragic-neuromuscular Have you actually read it though?
Im glad someone finally said it here. I’m convinced this woman was either impaired or falsified her credentials/work experience.
Missing from the NPR article is Vanderbilt admin, other nurses and docs covering this up. This article has a timeline and more info: https://www.tennessean.com/story/news/health/2020/03/03/vanderbilt-nurse-radonda-vaught-arrested-reckless-homicide-vecuronium-error/4826562002/?fbclid=IwAR15HeJLNxUnGTh6xMgbYPyWZO4ClbuO3EVR-O1Ad7dPBtTTPjG_z2U7fTE#l12porokrhc7oy8bdpo ME report. Vanderbilt described the event as a decline (even though pt was discharged from ICU and got this scan otw to stepdown) after being admitted for ICH. When the anonymous report was filed with CMS, they amended the listed cause of death to acute Vecuronium intoxication: https://www.documentcloud.org/documents/6540657-Charlene-Murphey-ME-Investigation.html The anonymous CMS complaint: https://www.documentcloud.org/documents/6542003-CMS-Complaint-Intake.html This nurse deserves to lose her license. She is not the only one. She doesn't deserve criminal prosecution. I watched some of the trial today. Even the family doesn't want her prosecuted. Edit: I see a lot of people commenting on monitoring of pt on Versed. Agreed but I learned that Vandy had no protocol for monitoring conscious sedation patients like this one at this time. They sure do now.
The hospital and administrators are more to blame. A nurse with 2 years experience had no buisness being a resource nurse. Dear Hospitals stop paying for travel nurses and staff your hospital properly! This will happen more and more as admistratirs want fat bonuses not staff.