Nurse faces prison for a deadly error

[krystee]

I cannot believe the hospital covered up the error, but the nurse is the only one who has to take the fall. It’s disgusting.

I can’t imagine ever applying for a job there after this if I worked in the medical field. I wonder if they’ll experience major recruiting issues.

[bronxgirl]

Mar 26, 2022 17:41:39 GMT -5 krystee said:

I cannot believe the hospital covered up the error, but the nurse is the only one who has to take the fall. It’s disgusting.

I can’t imagine ever applying for a job there after this if I worked in the medical field. I wonder if they’ll experience major recruiting issues.

Unfortunately it's like this all over.  My husband and I are both health care providers and have both experienced being strongly pressured by higher ups to do things we don't feel comfortable doing or break the rules. If you don't do it the message is you're not a team player, not a problem solver, being difficult, etc.  but if you do and something goes wrong, it gets 100% thrown back on you.  I've seen it happen to my colleagues, too. 

[wanderingback]

Mar 26, 2022 17:41:39 GMT -5 krystee said:

I cannot believe the hospital covered up the error, but the nurse is the only one who has to take the fall. It’s disgusting.

I can’t imagine ever applying for a job there after this if I worked in the medical field. I wonder if they’ll experience major recruiting issues.

It is not surprising at all that the hospital threw the nurse under the bus. At least it’s not surprising to those of us in healthcare. Hospitals are often mostly about their bottom line aka money.

[fryjack2]

A quarter of a million deaths occur every year from hospital errors.

Why did this particular death lead to criminal charges for the nurse when admittedly at fault for giving the wrong med, but the systems that were in place at the time ( from what I'm reading) that led to that error were very problematic.

As nurse manager, this really worries me. The culture of my hospital emphasizes identifying and reporting mistakes so that we can do a root cause analysis to prevent them from happening again. We are a teaching hospital. At some point in their career, every single person will make a mistake. Including myself. I was devastated and thought I would lose my license and job. I can't tell you how many times I have triple checked that I primed a line or relooked at a med because a family member was speaking to me as I was priming or scanning a dose, etc. When I know I did the task correctly, I still have that tiny what if sometimes.

Criminal charges in the healthcare world, when malice was not proved, is appalling. I'll be discussing this case and reinforcing our reporting expectations and supportive environment to staff on Monday as I know that some nurses were following this case and I want to make sure everyone feels supported. 

And also? Fuck Vanderbilt for trying to cover this up and breaking laws from the jump.

[basilosaurus]

Mar 26, 2022 19:26:41 GMT -5 wanderingback said:

Mar 26, 2022 17:41:39 GMT -5 krystee said:

I cannot believe the hospital covered up the error, but the nurse is the only one who has to take the fall. It’s disgusting.

I can’t imagine ever applying for a job there after this if I worked in the medical field. I wonder if they’ll experience major recruiting issues.

It is not surprising at all that the hospital threw the nurse under the bus. At least it’s not surprising to those of us in healthcare. Hospitals are often mostly about their bottom line aka money.

The act isn't at all surprising. But, I'll admit I'm still reeling a bit because I thought they were one of the better ones. Dolly Parton is a patron. They defied Bush's stem cell bullshit. I was part of a pilot program there to increase literacy amongst young children that now reaches tens of thousands. 

I think why it's so chilling is that it happened at a standout hospital, one that is competitive to work for, that is often in journals, known for standing up for its workers. They have a reputation of being saviors, and it's not entirely wrong. They do amazing work (and I've been tangentially part of it to my great gratitude).This sets a precedence in so many ways not covered by media.

[isabel]

I haven't seen it mentioned here... are nurses covered by insurance the same way that doctors are? I'm guessing not?

I find it incredibly fucked up that she's been convicted on these charges. This was not malicious. It was an error. Losing her license was enough.

[wanderingback]

Mar 26, 2022 23:14:37 GMT -5 isabel said:

I haven't seen it mentioned here... are nurses covered by insurance the same way that doctors are? I'm guessing not?

I find it incredibly fucked up that she's been convicted on these charges. This was not malicious. It was an error. Losing her license was enough.

Yes, nurses and other clinical staff in hospitals (pharmacists, etc) and outpatient settings are typically covered by the employers malpractice insurance. Nurses (and physicians) can purchase their own malpractice insurance as well if they want their own separate policy (and some physician jobs don’t provide malpractice so you have to get your own policy, typically per diem type jobs).

I think the nurse did make an error in note monitoring the patient in the CT suite after giving the medication like protocol calls for (per the documents the nurse says she wasn’t super busy), but agree that the criminal charges are not the right next step and the employer should also be held liable. I haven’t read if the family is filing any type of civil suit.

[sent]

Mar 26, 2022 22:58:41 GMT -5 basilosaurus said:

Mar 26, 2022 19:26:41 GMT -5 wanderingback said:

It is not surprising at all that the hospital threw the nurse under the bus. At least it’s not surprising to those of us in healthcare. Hospitals are often mostly about their bottom line aka money.

The act isn't at all surprising. But, I'll admit I'm still reeling a bit because I thought they were one of the better ones. Dolly Parton is a patron. They defied Bush's stem cell bullshit. I was part of a pilot program there to increase literacy amongst young children that now reaches tens of thousands. 

I think why it's so chilling is that it happened at a standout hospital, one that is competitive to work for, that is often in journals, known for standing up for its workers. They have a reputation of being saviors, and it's not entirely wrong. They do amazing work (and I've been tangentially part of it to my great gratitude).This sets a precedence in so many ways not covered by media.

PDQ. They threw my department under the bus all the time. Treated our residents as substandard compared to the other hospital residents just because they could get away with it while happily collecting the federal GME money that was sent to the hospital on behalf of each of us. While I was there, the medical center decided they would no longer accept Medicaid patients except in the ER and very narrow other departments (mine was one) because prestigious hospitals don't need the poors. I could go on but it's been over 13 years so my memory is fading on some of the less caustic stuff.  Yes do they amazing work but having experienced their BS personally, I'm not shocked at all this happened. 

[basilosaurus]

sent, I'm sorry for your experience. And, sadly, I'm not in the least surprised. I was there long ago, and our income came from grants which they were happy to brag about. This is just another in many where the tiniest of false support crumbles.

[shauni27]

Mar 26, 2022 9:19:12 GMT -5 wanderingback said:

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.

I will admit that I have no medical training and I was just parroting, clearly incorrectly, what some of the anesthesiology nurses I work with said. My understanding from what they told me was that this drug should not but available to teams other than anesthesiologists or that it should only be available in an RSI kit. But again, that is just what my colleagues were saying and I admit to not knowing any better. I absolutely misspoke.

[cville]

This is a shitty verdict.

[lostrn]

Mar 28, 2022 8:42:27 GMT -5 shauni27 said:

Mar 26, 2022 9:19:12 GMT -5 wanderingback said:

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.

I will admit that I have no medical training and I was just parroting, clearly incorrectly, what some of the anesthesiology nurses I work with said. My understanding from what they told me was that this drug should not but available to teams other than anesthesiologists or that it should only be available in an RSI kit. But again, that is just what my colleagues were saying and I admit to not knowing any better. I absolutely misspoke.

I don't think you misspoke. While the medication does need to available during an emergency, it shouldn't be quite that easy to grab. We've always had it available in an airway kit. Or in the procedural/surgical areas it's in the anesthesia med cart. So it's there, you can get it, you aren't going to easily grab it on accident.

As a nurse I feel a lot of conflict with this case. There were so many warnings and red flags that just got ignored by the nurse that day. And she has stated that day she didn't feel tired, the unit wasn't particularly understaffed or overly busy. The vial cap was clearly labeled "paralyzing agent". You don't have to reconstitute versed. Mistakes do happen, I know that but this one was so severe and really so avoidable with one double check of the medication. Jail time? I don't know how I feel about.

People say the family forgave her...well no, the hospital reached a settlement with them but they aren't allowed to talk about the case.

[basilosaurus]

Mar 28, 2022 8:42:27 GMT -5 shauni27 said:

Mar 26, 2022 9:19:12 GMT -5 wanderingback said:

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.

I will admit that I have no medical training and I was just parroting, clearly incorrectly, what some of the anesthesiology nurses I work with said. My understanding from what they told me was that this drug should not but available to teams other than anesthesiologists or that it should only be available in an RSI kit. But again, that is just what my colleagues were saying and I admit to not knowing any better. I absolutely misspoke.

You spoke as those you had you you another. You do not.  

[somersault72]

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

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.

1,000%

All the healthcare systems in this area are doing a really big push to decrease/eliminate errors within their systems. One of the big things they're encouraging is transparency when something does occur (even a near miss) and they keep reiterating that you won't be punished (supposedly in most cases you can report anonymously). This case...is not going to bode well for that. I know some nurses who are pretty upset over this and I get it. We have a HUGE nursing shortage here, like much of the country, and I feel like something like this is going to either cause people not to report or drive more nurses from the profession--or both. Just like the bullshit legislature that's going to drive a lot of the good teachers away.

[shauni27]

Mar 28, 2022 10:30:11 GMT -5 basilosaurus said:

Mar 28, 2022 8:42:27 GMT -5 shauni27 said:

I will admit that I have no medical training and I was just parroting, clearly incorrectly, what some of the anesthesiology nurses I work with said. My understanding from what they told me was that this drug should not but available to teams other than anesthesiologists or that it should only be available in an RSI kit. But again, that is just what my colleagues were saying and I admit to not knowing any better. I absolutely misspoke.

You spoke as those you had you you another. You do not.  

I am not being snarky, but huh? I genuinely do not know what you are saying here.

Regardless, I stated that I misspoke and that I should not have said what I did.

[pooh8402]

Mar 26, 2022 23:14:37 GMT -5 isabel said:

I haven't seen it mentioned here... are nurses covered by insurance the same way that doctors are? I'm guessing not?

I find it incredibly fucked up that she's been convicted on these charges. This was not malicious. It was an error. Losing her license was enough.

Yes. There is hospital insurance but I have never trusted them (this case highlights why). And nurses can carry their own malpractice insurance, which I have for a while.

[maudefindlay]

There is a petition asking for clemency with 150k signatures.

[sent]

Whatever they did that caused this nurse to have this fate is unacceptable from where I sit. This prestigious medical center should have settled with this family and never let this case see the light of day.

PDQ - I got an email asking for a donation to the university with lots of feel-good words. DELETE.

[Saudade]

Mar 31, 2022 16:34:26 GMT -5 sent said:

Whatever they did that caused this nurse to have this fate is unacceptable from where I sit. This prestigious medical center should have settled with this family and never let this case see the light of day.
[




They did settle with the family

[sent]

Saudade, if Vanderbilt settled with the family, how did the nurse end up in this situation?

My knowledge of medical malpractice is very small. I would have thought if the medical center is settling, they would put in clauses that the family can't go out there and sue the individual doctors and nurses for malpractice to protect their staff. Someone reported her to the licensing board and the board took action. I don't disagree with that part. But how did she end up on trial for murder? The article doesn't cover this.

[scout8]

Mar 31, 2022 20:52:29 GMT -5 sent said:

Saudade , if Vanderbilt settled with the family, how did the nurse end up in this situation?

My knowledge of medical malpractice is very small. I would have thought if the medical center is settling, they would put in clauses that the family can't go out there and sue the individual doctors and nurses for malpractice to protect their staff. Someone reported her to the licensing board and the board took action. I don't disagree with that part. But how did she end up on trial for murder? The article doesn't cover this.

I think you are confusing civil and criminal cases. 

The family sued Vanderbilt (and probably the nurse too) in civil court for medical malpractice. Vanderbilt settled and paid monetary damages to the family.

The state filed criminal charges against the nurse for murder. 

[mysteriouswife]

Wrong post 🥴

[wanderingback]

Mar 31, 2022 20:52:29 GMT -5 sent said:

Saudade, if Vanderbilt settled with the family, how did the nurse end up in this situation?

My knowledge of medical malpractice is very small. I would have thought if the medical center is settling, they would put in clauses that the family can't go out there and sue the individual doctors and nurses for malpractice to protect their staff. Someone reported her to the licensing board and the board took action. I don't disagree with that part. But how did she end up on trial for murder? The article doesn't cover this.

Civil and criminal cases are 2 separate things.
Vanderbilt settled with the family a couple of years ago. The details of the settlement likely won’t ever be revealed. There might be a clause that the family can’t sue individual doctors or nurses from the case, which has not happened. A criminal case was brought against the nurse.

So fast forward to more recently further investigation was done by CMS and Vanderbilt kind of gets in more trouble from Medicare and has to essentially make a report of how they’ll fix the error but don’t release it publicly.
Then, criminal charges are brought against the nurse separately. Has nothing to do with the above civil settlement that the family made with Vanderbilt.

[sent]

wanderingback, scout8,

So Tennessee went after the nurse? Oh wow, I wonder why someone in the government felt the need to make an example out of this situation.

[minzy]

sent Yes, there are civil and criminal proceedings and they are different. I know of a case where a physician had four different actions against him simultaneously - criminal charges brought by the state, the state’s medical board went after his medical license, the DEA went after his ability to prescribe controlled substances, and a family sued him for wrongful death. I think a divorce also ran parallel to some of that, too.

[goldengirlz]

Mar 28, 2022 8:48:46 GMT -5 cville said:

This is a shitty verdict.

It’s a shitty verdict but it never should have gotten to this point to begin with.

Tennessee has a lot to recommend it but it’s run by a bunch of shitty people. From what I’ve read, it’s pretty rare to bring criminal charges for a medication error.

[basilosaurus]

Apr 1, 2022 7:28:16 GMT -5 jennyparnassus said:

Mar 31, 2022 23:42:22 GMT -5 goldengirlz said:

It’s a shitty verdict but it never should have gotten to this point to begin with.

Tennessee has a lot to recommend it but it’s run by a lot of shitty people. From what I’ve read, it’s pretty rare to bring criminal charges for a medication error.

It's disgusting that Nashville honors the Donelson family. What a disgusting bunch of people. 

In what way? In my years there all I knew about Donelson was the road.

It took them decades to change confederate hall to memorial and involved years of litigation and finally a payout to UDC. They still have calhoun hall. So, I'm not at all surprised; I just don't remember anything about it. The name is everywhere in Nashville.

[basilosaurus]

I know all that about the Donelson family now. I don't remember when or why I learned, but it was after I'd moved. I'm asking in what way Vandy honors them today.