Nurse faces prison for a deadly error

[wesleycrusher]

www.npr.org/sections/health-shots/2022/03/22/1087903348/as-a-nurse-faces-prison-for-a-deadly-error-her-colleagues-worry-could-i-be-next

Four years ago, inside the most prestigious hospital in Tennessee, nurse RaDonda Vaught withdrew a vial from an electronic medication cabinet, administered the drug to a patient and somehow overlooked signs of a terrible and deadly mistake.


This week, she goes on trial in Nashville on criminal charges of reckless homicide and felony abuse of an impaired adult... If convicted of reckless homicide, Vaught faces up to 12 years in prison.



This is being followed by a lot of nurses I know. Having used the machines in the past I can see how they would instill complacency and a sense of security, especially when nurses are being stretched thin (which has even worsened with COVID). 

[Bad Dingo]

From what I read this was very reckless with multiple safe-guards and basic knowledge bypassed.

[karinothing]

Mar 24, 2022 10:48:58 GMT -5 Bad Dingo said:

From what I read this was very reckless with multiple safe-guards and basic knowledge bypassed.

Yeah that is what I read too. She ignored multiple pop up warnings and failed to verify the physical drug was correct before administering it to the patient. Also the paracletic drug was a powder that had to be mixed with liquid in order to administer and the other drug was not. I don't know. That is a lot to ignore.  

[shauni27]

I can give a pass to the system popping up warnings that you override--that happens in systems all the time; you know it is just part of your normal process to say "override" or "ignore" so you don't even read the messages.

But the powder that needed to be mixed AND the then not reading the vial first before use (which would show both the name she was not expecting as well as the warning on it) seems very problematic.

Talking 100% based on emotion and having zero real understanding of law, it seems the criminal case is overkill, but at the very least she should have lost her license and Vanderbilt (and really all hospitals/medical settings) should be taking a REALLY close eye at how they are 1) training their staff and 2) improving their electronic systems so overrides are NOT a regular occurrence.

[shauni27]

also, I hope Vanderbilt faced some consequences as well; the medication she accidentally used should not even have been in the machine she was accessing. It really should only be available to anesthesiologists and in a machine with the counter-drug as well.

[schrodinger]

She certainly shares some of the blame for this, but I think there's a lot I want to know before I think it rises to criminal charges. What percentage of meds are withdrawn with an override? If it's a significant number, then clearly the override system is viewed as a nuisance, not as a safeguard. Why can't the electronic system return a search on both generic and common name? If the order was for Versed, then she shouldn't have to "translate" to midazolam to get the meds dispensed.

Once she had the meds, I can understand how warnings were ignored. I suspect it was a task completion bias where she had the meds, and was going to complete the task of giving the meds. It's a common phenomena in plane crashes where pilots ignore unsafe landing conditions and attempt a landing anyways despite alarms or warnings that it's unsafe. They focus on completing a task that they have been assigned and will ignore signs that they are doing something unsafe.

[Saudade]

Until you've been in this situation, it's hard to understand. We don't know how overworked and understaffed the unit was. We don't know if a provider was screaming in her face. I've seen that and I've seen the result.

shauni27, that is not true. We keep all sorts of paralytics in our Pyxis that we can access at any time. All sorts of meds come in different constitutions. For example, I've never seen antibiotics in powder form until my current job. I had no idea because my old unit had premixed bags or pharmacy sent up made bags.

We have certain meds that are available through override, including paralytics, because in an emergency you don't have time to enter the order, wait for pharmacy to verify, and then pull the med.

However, because of that, the onus is on everyone to ensure the right med is given.

If you want a list of all the pure shit I've seen as a result of systemic problems, I'll gladly write a post. This should be something that people use to fight the system instead of blaming the individual nurse.

[shauni27]

Saudade, interesting, my experience has been different. I appreciate you clearing that up.

I agree, there are so many systematic issues that lead to major problems. I agree with you as well; that should be used to fight said system, not the individual in criminal court.

[jinkies]

I don't deny that she shares some blame, but the fact that Vanderbilt is throwing her under the bus and taking no responsibility is shameful. From the article:

Vaught said that at the time of Murphey's death, Vanderbilt was instructing nurses to use overrides to overcome cabinet delays and constant technical problems caused by an ongoing overhaul of the hospital's electronic health records system.

Murphey's care alone required at least 20 cabinet overrides in just three days, Vaught said.

"Overriding was something we did as part of our practice every day," Vaught said. "You couldn't get a bag of fluids for a patient without using an override function."

The article also says that the cabinet manufacturer modified the software to require entering 5 letters of the medication name and not just the first two, but Vanderbilt didn't implement the update. 

To me it seems like the entire system failed, and only the lowest person in the chain is being held accountable.

ETA: reading comprehension fail on my part-- the manufacturers updated the software in response to this case, not before it. I still think that the system is happy to let the nurse take the fall, instead of acknowledging and trying to fix a wider problem.

[bears]

schrodinger,I've heard the pilot phenomena you described described as "get there-itis." It happens so much more often when pilots are stressed by poor working conditions and bad communication between staff.

Saudade,this problem seems so systemic and it's so shitty how we, as a society, are more likely to blame one individual than the system that incentivizes unsafe working conditions to save money.

[dirtyred]

As someone who used to be a QA person, it is NEVER just one error. It usually takes a sting of errors for something like this to occur, and the last one in line takes the blame.  I hope she gets a lawyer well versed in this and they do an extensive root cause analysis because I guarantee you there are others at fault.

[CrazyLucky]

I do a lot of root cause analysis, and one thing that is drilled into me is that if your root cause is someone screwed up, you didn't find your root cause. If overrides are part of a normal day for a nurse, then it's not a functioning safeguard. We have alarms at work, and take great pains to ensure alarms are meaningful. If an operator has pages of alarms going off, is he really going to look at every single one? Or is he just going to hit the "silence alarm" button. I don't doubt the nurse made a mistake, but it seems like there are big systemic issues, like fatigue, "deviation acceptance," and not using the manufacturers safety suggestion of more than two letters required. Plenty of blame to go around, but shit rolls downhill, and it looks like the nurse will take all the blame. Which is BS even if she wasn't criminally charged.

[sent]

I am very familiar with this prestigious medical center and having lots of feelings about the medical center itself not being the subject of this lawsuit and instead the nurse is taking the fall. Lose your license, I can see that. Murder? Idk how that conclusion is happening here. Does she have like a pattern of administering lethal medications?

Are there smarter cabinets out there? I can totally see the brand name/generic name throwing someone off in a tense moment. Seems like there should be more info in this day and age like a screen on the cabinet so mistakes in names and spellings could be minimized and overrides wouldn’t be a common occurrence.

****I have never used one of these cabinets and I am not a lawyer.

[boiler717]

From what I’ve seen covered, the hospital system has been extremely shady in their settlement with the patients family and throwing the nurse under the bus. I am not sure how I feel about criminal charges without intent, especially when the system is set up for you to fail but really don’t think I agree. I do believe in just culture and holding people accountable when it’s clear that there was individual wrongdoing, but that is different than criminal charges. This will impact patient safety in a negative manner if people are afraid to come forward.

[chilerellanos]

I am an OB nurse, and so we don’t have meds like this in our Pyxis.

But we pull meds out on override all the time, and yeah, every time you pull them out, warnings pop up and you just have to ignore them.

I do feel like criminalizing med errors is just going to make nurses and hospitals less likely to report and be transparent.

[livinitup]

Are we really criminalizing nurses for showing up to work and working with shitty med systems that they didn’t buy (or want) with stupid *override systems* just to get patients their prescribed meds We are blaming THE NURSES using the shitty system ?? Really?

We know the med systems are expensive and actually really shitty to use !!!

[minzy]

There was a study published by the IOM about twenty years ago that estimated 98,000 Americans a year die from medical error. I did a fellowship that looked at the systemic causes of that. We studied what Toyota did in their production lines, which may not seem entirely relevant, but a local hospital was able to employ some of the same sigma 6 type concepts, and significantly reduced MRSA infections. The focus was all about the process and there was a huge push to change the culture on reporting errors. Atul Gawande wrote a great book about medical error called Complications. bookshop.org/books/complications-a-surgeon-s-notes-on-an-imperfect-science/9780312421700?gclid=CjwKCAjwrfCRBhAXEiwAnkmKmU6k2EqUzHWhLv7hntQ0RIAnOxnKu4A9HT5j8mxAXeRBdE1IbprsZxoCQtcQAvD_BwE
Fascinating stuff.

How tragic this case is, all around. I can imagine her prosecution is demoralizing for nurses and will have a chilling effect on healthcare providers coming forward if they make a non-fatal error. Maybe someone can skate by with a few of those but if you can improve the underlying process you’d want people to report report report and not penalize them for doing so.

[wise_rita]

Mar 24, 2022 19:26:22 GMT -5 chilerellanos said:

I do feel like criminalizing med errors is just going to make nurses and hospitals less likely to report and be transparent.

And do as the teachers are doing and flee the profession.

[basilosaurus]

Mar 25, 2022 5:01:24 GMT -5 wise_rita said:

Mar 24, 2022 19:26:22 GMT -5 chilerellanos said:

I do feel like criminalizing med errors is just going to make nurses and hospitals less likely to report and be transparent.

And do as the teachers are doing and flee the profession.

Already happening. 

Criminalizing a med error is a very bad direction to take.

[letsgetweird]

I can see how this happened, sometimes at work you're on autopilot. I'm truly sorry the patient lost her life.

The nurse has already lost her license. I feel that is appropriate punishment. A criminal case is overkill.

[wawa]

Mar 24, 2022 21:27:19 GMT -5 minzy said:

There was a study published by the IOM about twenty years ago that estimated 98,000 Americans a year die from medical error. I did a fellowship that looked at the systemic causes of that. We studied what Toyota did in their production lines, which may not seem entirely relevant, but a local hospital was able to employ some of the same sigma 6 type concepts, and significantly reduced MRSA infections. The focus was all about the process and there was a huge push to change the culture on reporting errors. Atul Gawande wrote a great book about medical error called Complications. bookshop.org/books/complications-a-surgeon-s-notes-on-an-imperfect-science/9780312421700?gclid=CjwKCAjwrfCRBhAXEiwAnkmKmU6k2EqUzHWhLv7hntQ0RIAnOxnKu4A9HT5j8mxAXeRBdE1IbprsZxoCQtcQAvD_BwE
Fascinating stuff.

How tragic this case is, all around. I can imagine her prosecution is demoralizing for nurses and will have a chilling effect on healthcare providers coming forward if they make a non-fatal error. Maybe someone can skate by with a few of those but if you can improve the underlying process you’d want people to report report report and not penalize them for doing so.

I think a lot of industries could stand to take a close look at how US manufacturing has gotten from how things were during the industrial revolution where people died in factories ALL THE TIME to now.  (mine is one, I bring this shit up at work a lot)

People in industry joke about OSHA being a pain in the ass, but the regs and changes in expectations, workflow and processes (like, tag in/tag out procedures being ABSOLUTELY MANDATAORY and just part of company culture) made an amazing difference in the rate of serious injuries.  I think steel industry it was something like a 90% drop in injury rates. Interestingly for this case - a big part of that change in culture was that the liability was placed on the part of the employer rather than the employee....so they were incentivised to spend money on training and appropriate equipment for safer operations.....

[Michelle]

I've been following this story and am appalled. She certainly made egregious errors in judgment. But if after peer review, it is determined she acted recklessly, she should lose her license, not be criminally charged. She didn't intentionally or maliciously intend to hurt the patient.

A lot of the social media talk examines how she made the error, reported the error, the organization tried to cover up the error instead of taking accountability for their systems, staffing levels, etc. that put the patient at risk, and shared ownership in what happened.

I get why a company would try to divert attention due to risk and liability. But you don't make a person the fall guy when you realize you helped put her in that position. That is unethical and will drive nurses away from reporting errors, diminishing any culture of safety you might have tried to have.

[neverfstop]

Just from reading comments on here, this sounds like a shitty situation. I feel like this is a recurring theme....big systems are designed to maximize profits and speed, people are pushed to work in them to the best of their ability, and when there is collateral damage or the system fails, all the responsibility and blame is offloaded on an individual instead of looking at system (or corporate) failures and responsibilities.

[bears]

She was convicted: www.tennessean.com/story/news/crime/2022/03/25/radonda-vaught-trial-vanderbilt-nurse-jury-verdict/7154135001/?csp=chromepush

[af1212]

Mar 25, 2022 13:10:28 GMT -5 bears said:

She was convicted: www.tennessean.com/story/news/crime/2022/03/25/radonda-vaught-trial-vanderbilt-nurse-jury-verdict/7154135001/?csp=chromepush

Oh goodness

[wildrice]

Jeez. I hope she gets a minimal sentence. In general, I am really opposed to criminal charges for things that are done by accident. From what (little) I've read, it seems she's truly remorseful and feels terrible that this happened. She is going to live with it the rest of her life and has lost her career over the mistake already. Why punish her further?

[ellipses84]

Mar 25, 2022 8:58:36 GMT -5 wawa said:

Mar 24, 2022 21:27:19 GMT -5 minzy said:

There was a study published by the IOM about twenty years ago that estimated 98,000 Americans a year die from medical error. I did a fellowship that looked at the systemic causes of that. We studied what Toyota did in their production lines, which may not seem entirely relevant, but a local hospital was able to employ some of the same sigma 6 type concepts, and significantly reduced MRSA infections. The focus was all about the process and there was a huge push to change the culture on reporting errors. Atul Gawande wrote a great book about medical error called Complications. bookshop.org/books/complications-a-surgeon-s-notes-on-an-imperfect-science/9780312421700?gclid=CjwKCAjwrfCRBhAXEiwAnkmKmU6k2EqUzHWhLv7hntQ0RIAnOxnKu4A9HT5j8mxAXeRBdE1IbprsZxoCQtcQAvD_BwE
Fascinating stuff.

How tragic this case is, all around. I can imagine her prosecution is demoralizing for nurses and will have a chilling effect on healthcare providers coming forward if they make a non-fatal error. Maybe someone can skate by with a few of those but if you can improve the underlying process you’d want people to report report report and not penalize them for doing so.

I think a lot of industries could stand to take a close look at how US manufacturing has gotten from how things were during the industrial revolution where people died in factories ALL THE TIME to now.  (mine is one, I bring this shit up at work a lot)

People in industry joke about OSHA being a pain in the ass, but the regs and changes in expectations, workflow and processes (like, tag in/tag out procedures being ABSOLUTELY MANDATAORY and just part of company culture) made an amazing difference in the rate of serious injuries.  I think steel industry it was something like a 90% drop in injury rates. Interestingly for this case - a big part of that change in culture was that the liability was placed on the part of the employer rather than the employee....so they were incentivised to spend money on training and appropriate equipment for safer operations.....

Totally agree. This has been my experience in the construction industry, particularly with federal work. The responsibility and consequences are on the employer, training and issues are taken seriously and there are less accidents as a result.

[basilosaurus]

Because it's my 2nd degree, I probably have far less experience but more recent classroom experience (a decadeish ago) than most of the nurses here.

Do you know how often I heard about the swiss cheese model, that we were the last line of defense in a system predisposed to error? Every class, multiple times during the class. And we were admonished to never fear to speak up because hiding mistakes is far more dangerous, and it was incumbent on us to report so that the systems could be fixed. I'd thought this was a changing of old ways to discourage silence.

I'm livid about this outcome as should every person who ever thinks they'll need to receive healthcare. There is no justice here. There is only increased future risk.

I also feel this personally as I did my first degree there. I volunteered at that hospital. I worked later on in research there. I had friends and classmates who also later got 2nd nursing degrees and NPs at that nursing school. There were so many things I absolutely hated about my college experience, but I had the deepest faith in the hospital.

Home of the commode doors indeed. (school mascot is commodore in case that reference is obscure to some)

[tacom]

Go after the institution or the system; don’t destroy the person who was unlucky enough to face the consequences of mistakes we are all set up to make.

This outcome is horrible.

[wanderingback]

Mar 24, 2022 11:26:34 GMT -5 shauni27 said:

also, I hope Vanderbilt faced some consequences as well; the medication she accidentally used should not even have been in the machine she was accessing. It really should only be available to anesthesiologists and in a machine with the counter-drug as well.

Why do you say it shouldn’t have been in the machine?
Especially during emergency situations certain medications need to be accessible, you can’t wait for them to come up from the pharmacy.