# Tenn. nurse charged for med error



## Jmartjrmd (Jul 28, 2021)

@Leeda.the.Paladin @lavaflow99 
Discussion  for anyone but in particular to 
 all my fellow Healthcare workers and legal minds this is an interesting case from 4 years ago.  It's a hot topic in nursing and legal circles because the Tenn. noard of nursing just stripped her license so the case is front and center again.   I watched the bon trial. What are your thoughts on this case?  Should she have been criminally charged?

Back story
This nurse was assigned as a resource nurse.  She was asked to go to CT to give patient some versed because patient was anxious.  She was precepting  and had him with her.
She goes to accudose but versed isn't on patient profile yet so she goes to a few machines to check those.  It hadn't populated yet so she does an override
She types in Ve and picks first thing that pops up.
She doesn't look at vial, instead flips vial and reconstitute according to directions.
She goes and looks for computer to scan but learns the department doesn't have a scanner.
Because the pt. had contrast she feels like she needs to give the med because they needed the scan or the pt would have had to wait another day.
She gives the med then leaves for her next task in the ER.  She takes vial with her to scan later.
After ER they go back to ICU where she gives the med to the nurse assigned to the patient so they could waste the excess when the pt. returns.  They hear code blue called in PET scan.  The patients family is outside her room and ask if that's their family member.  She says she doesn't know but thinks it probably is.  
So trying to shorten this a little..... the nurse goes down to see if that was the same patient and it was.  At that time they'd gotten her "stable" and return to icu with her critical.
So the nurse she handed the bag to asks her if that was what she gave the patient.  She says yes and he informs her that it was not versed but vecuronium and hands her the bag back. She tells him to give the bag to their charge nurse.   She goes into the room and informs the team that she'd made the med error because the team couldn't figure out what went wrong.  
The patient dies I think the next day.

She was charged with abuse of an adult and negligent homicide.  
What say you?

I have alot more details but wanted to discuss because the outcome of this case will have a huge impact on Healthcare.  She's facing up to 10 years in prison.


----------



## awhyley (Jul 28, 2021)

There was alot to unpack up there, but from what I gather, the nurse selected *Ve*curonium instead of *Ve*rsed due to alphabetical mixup.  I would classify it as negligent as she should have checked before administering.  She should get some jail time, but if there was no malicious intent behind her actions, I'm not sure where the ten years is coming from.


----------



## Jmartjrmd (Jul 28, 2021)

awhyley said:


> There was alot to unpack up there, but from what I gather, the nurse selected *Ve*curonium instead of *Ve*rsed due to alphabetical mixup.  I would classify it as negligent as she should have checked before administering.  She should get some jail time, but if there was no malicious intent behind her actions, I'm not sure where the ten years is coming from.


Correct but my issue with defending her is she missed an awful lot of self safety checks.
First versed doesn't come in powder so she wouldn't have needed to reconstitute.   Being a 2 year icu nurse she should know that but even if she didn't had she just done the basic thing andooked at the vial she could have caught her error..  She had another nurse ( although new) that she could have done a double check with
She didn't look at the vial
She gave the med on an unmonitored patient and just left to do her next task
I feel awful for her but this was 100% preventable.
A lot of people are saying it was a systems issue which is true but it's not all on them.  Now what they did after learning of the error is criminal.


----------



## Leeda.the.Paladin (Jul 28, 2021)

Jmartjrmd said:


> She types in Ve and picks first thing that pops up.
> She doesn't look at vial, instead flips vial and reconstitute according to directions.
> She goes and looks for computer to scan but learns the department doesn't have a scanner.


I mean….all of this, wow. Do they not do a 2 person check off on versed administration there? 

I don’t know that she should be charged but I do think she should lose her license. I mean, everyone makes mistakes, but that is why there are so many systems in place to lessen the chance of that happening. 

But I think the hospital was trying to cover their own behinds by not initially reporting  this, and trying to hide the cause of death.


----------



## B_Phlyy (Jul 28, 2021)

Jmartjrmd said:


> Discussion  for anyone but in particular to
> all my fellow Healthcare workers and legal minds this is an interesting case from 4 years ago.  It's a hot topic in nursing and legal circles because the Tenn. noard of nursing just stripped her license so the case is front and center again.   I watched the bon trial. What are your thoughts on this case?  Should she have been criminally charged?
> 
> Back story
> ...



There was no written order for the med. This alone should have made her stop and verify with an attending is this what was ordered.
Even just typing the first 3 letters during the override would have shown she needed to look further to ensure she was getting the correct med. Scanner would have told her this as well.
Also, even though patient was in ICU, she was stable enough to get the CT so it wasn't like it was an active emergency. The nurse definitely could have made sure the doctor had entered the order before giving it.

Yeah, she needed to lose her license. And her being a professional healthcare worker is why they're likely hitting her with the negligent homicide. Not sure where they are getting 10 years of jail time from.


----------



## Jmartjrmd (Jul 28, 2021)

B_Phlyy said:


> There was no written order for the med. This alone should have made her stop and verify with an attending is this what was ordered.
> Even just typing the first 3 letters during the override would have shown she needed to look further to ensure she was getting the correct med. Scanner would have told her this as well.
> Also, even though patient was in ICU, she was stable enough to get the CT so it wasn't like it was an active emergency. The nurse definitely could have made sure the doctor had entered the order before giving it.
> 
> Yeah, she needed to lose her license. And her being a professional healthcare worker is why they're likely hitting her with the negligent homicide. Not sure where they are getting 10 years of jail time from.


There was an order in epic but it hadn't been put on the profile for their med system yet.  ( MAR)   which is why she did the override. 
She did look for a scanner but they didn't have one in the CT department.
I think the 10 years is the max she faces with the 2 counts she was charged with.
The trial starts 3/22 and she entered not guilty plea.


----------



## Evolving78 (Jul 28, 2021)

Why would she not scan the patient’s id before administering the medication?


----------



## Jmartjrmd (Jul 28, 2021)

Evolving78 said:


> Why would she not scan the patient’s id before administering the medication?


she was off the unit down in the CT department..if I recall it was like 2 floors down from the ICU...and that department didn't have scanners on their computers.


----------



## Leeda.the.Paladin (Jul 28, 2021)

@Jmartjrmd it just seems like she wouldve been even more sure to do the right thing with her precepting someone.




Evolving78 said:


> Why would she not scan the patient’s id before administering the medication?


It said there was no scanner in that department ….Which would be even more reason to be careful and double check everything


----------



## Everything Zen (Jul 28, 2021)

The nurse is reckless and should lose her license - PERIOD. Jail-time? Now that I read into it- I dunno.

The hospital needs to review policies and SOPs. Clearly preceptors need more oversight. UPDATE: Googles hospital- Not Vanderbilt! Damn. Lol

The fact that staff can take medication from Accudose by typing in 2 letters appears to be a major potential root cause. The system should make the staff confirm the medicine before dispensing or even say it out loud bc that’s just cray. Possibly require second verification for potentially lethal drugs? Don’t keep them in such a loose system with the aspirin… IJS


----------



## Everything Zen (Jul 29, 2021)

Nah - this goes way deeper than the nurse. Sounds like Vandy tried to do a cover-up! Lordt!









						RaDonda Vaught: Vanderbilt largely to blame for deadly medication error, attorney says
					

RaDonda Vaught, a former Vanderbilt nurse, has been charged with reckless homicide for a medication error that killed a patient in 2017.



					www.tennessean.com


----------



## Leeda.the.Paladin (Jul 29, 2021)

I was surprised it was Vanderbilt too.

I just read that the nurse had also settled with the family for an undisclosed amount.

what a mess


----------



## Jmartjrmd (Jul 29, 2021)

The cover up was awful only disclosed because of an anonymous tip.


----------



## naturalgyrl5199 (Aug 5, 2021)

I see some root cause here as well. Definitely that "ver" coming up could be improved. I have a book called "Medications and Mothers Milk" and there are thousands of medications there...dozens have the same 1st 3 letters. 

I don't like override systems. The idea you can skip certain safety checks in dealing with drugs is scary.
However as professionals, RNs have a standard of care and practice they have to follow and we rely on. I can tell you guys are great professionals cause you all quickly sniffed out the problems.


----------



## Jmartjrmd (Aug 5, 2021)

naturalgyrl5199 said:


> I see some root cause here as well. Definitely that "ver" coming up could be improved. I have a book called "Medications and Mothers Milk" and there are thousands of medications there...dozens have the same 1st 3 letters.
> 
> I don't like override systems. The idea you can skip certain safety checks in dealing with drugs is scary.
> However as professionals, RNs have a standard of care and practice they have to follow and we rely on. I can tell you guys are great professionals cause you all quickly sniffed out the problems.


Part of the  problem in nursing is staffing ratios.  As technology, research and treatment options improve patients are sicker and sicker but administration keeps finding ways to cut corners and one huge way is not having mandatory staffing ratios for nurses.  Onr nurse taking care of 8 to ten patients with no tech is unsafe.  But even with a tech it's unsafe.  California is the only state with laws across the board.  They tried to pass a mandatory staffing law in Massachusetts and voters shot it down.  The campaign put on by those in healthcare administration tell you all you need to know..  I think the public needs to be educated on what exactly nurses do and how it impacts their (the patients) care.   Just going through tictok I can see clearly most people do not understand.


----------



## Jmartjrmd (Aug 5, 2021)

naturalgyrl5199 said:


> I see some root cause here as well. Definitely that "ver" coming up could be improved. I have a book called "Medications and Mothers Milk" and there are thousands of medications there...dozens have the same 1st 3 letters.
> 
> I don't like override systems. The idea you can skip certain safety checks in dealing with drugs is scary.
> However as professionals, RNs have a standard of care and practice they have to follow and we rely on. I can tell you guys are great professionals cause you all quickly sniffed out the problems.


Also, and I'm sure it is not everywhere, but Versed should be listed as Midazolam with its brand name  Versed in parentheses.  You also don't reconstitute it.
Also Vecuronium, in my experience, has paralytic written across the front as a warning.
We need the ability to override in certain situations so while problematic here  there are safety measures built into an override.
I just think she wasn't experienced enough to be a float, she was careless. and Vandy needs to tighten up their processes.
Vandy also did ALOT of lying trying to save face it's unbelievable.


----------



## naturalgyrl5199 (Aug 5, 2021)

Jmartjrmd said:


> Also, and I'm sure it is not everywhere, but Versed should be listed as Midazolam with its brand name  Versed in parentheses.  You also don't reconstitute it.
> Also Vecuronium, in my experience, has paralytic written across the front as a warning.
> We need the ability to override in certain situations so while problematic here  there are safety measures built into an override.
> I just think she wasn't experienced enough to be a float, she was careless. and Vandy needs to tighten up their processes.
> Vandy also did ALOT of lying trying to save face it's unbelievable.


I was also thinking she should have been able to lean on her expertise, education and training so that the override didn't result in an error. But you seemed to sniff out quickly she wasn't experienced. Lack of experience and small errors can get you fired.


----------



## Jmartjrmd (Aug 5, 2021)

naturalgyrl5199 said:


> I was also thinking she should have been able to lean on her expertise, education and training so that the override didn't result in an error. But you seemed to sniff out quickly she wasn't experienced. Lack of experience and small errors can get you fired.


You're right.  I've said the same in other groups where this has been debated.  Medication administration and the 5 to 7 rights of med administration  is drilled into our learning.
She failed that at the most basic level.  
Right med... she admitted that she never looked at the vial.  How do you do that?
I still don't think she's a criminal but I can't give her a hard pass for her mistake and how the hospital played a role.  They did but she failed to protect herself at the most basic of things learned in nursing school.  Guilty of malpractice but not a criminal act.

The more I learn about the cover up the more I agree with the people saying the system failed her in addition to her failing herself.

Nurses hate being my nurse lol because I'm extra extra.  I tell them not to bring me any meds unless it's in the package and I can see it.  I even ask to see IV meds before they hang it.
But I don't care.  It's my life on the line as much as it is their license.  If I can't see what you're giving then I'm not getting it.

I'm not rude about it but I get a lot of attitude and pushback.    I'm like I'm one of ya'll lol I just need to know.  
The scanner gives me some  peace of mind however I've seen a provider enter orders on the wrong patient.  In that case it's on your profile so yes it's scanned saying right patient, right drug but in reality it's not because of the provider error.   .I encourage everyone to verify what they are giving you and why.


----------



## lavaflow99 (Aug 5, 2021)

Yeah she made a major mistake and ignored the various checks and balances.  I am alarmed that she didn't look at the label  And she did all this while precepting?  Not a good look!

But Vanderbilt messed up big time too.  No scanner in the department?   And there needs to be better check and balances with the med machine especially with meds that are close in spelling or sound alike.  Like how is it possible a med is able to be administered without scanning?  I don't think I have seen that before.

But a criminal and jail time?  That is a bit extreme.  Losing her license should be enough punishment.

Vanderbilt needs to be hit hard financially and sucks how they are leaving her out to dry.


----------



## naturalgyrl5199 (Aug 6, 2021)

Jmartjrmd said:


> You're right.  I've said the same in other groups where this has been debated.  Medication administration and the 5 to 7 rights of med administration  is drilled into our learning.
> She failed that at the most basic level.
> Right med... she admitted that she never looked at the vial.  How do you do that?
> I still don't think she's a criminal but I can't give her a hard pass for her mistake and how the hospital played a role.  They did but she failed to protect herself at the most basic of things learned in nursing school.  Guilty of malpractice but not a criminal act.
> ...


You wouldn't be surprised to know but I want to scream how on the most basic level I ask people what medicine they or their children are on and many of them--even though they can pronounce it they have no idea what its for. I tell them, please review the name, genric name and what exactly the medication does. I also gently remind them, please don't ever accept a prescription and you don't know what its for. Even the pharmacist who is dispensing it will gladly take the 30 seconds needed to explain it. They (the pharmacist or the techs) ask you (do you have any questions about the medications you're receiving?) cause in FL its law.


----------



## Everything Zen (Aug 10, 2021)

MD students only take one sememster of pharmacology but I digress…


----------



## Jmartjrmd (Apr 14, 2022)

Well she was tried and convicted!
I think sentencing is in a few weeks.


----------



## lavaflow99 (Apr 14, 2022)

Very surprised.  And folks in the medical world are worried. This could set a new precedent.









						As a former Vanderbilt nurse awaits sentencing for a medical error, her conviction sparks widespread worry
					

The name RaDonda Vaught is now well-known by nurses nationwide. Her negligent homicide conviction for a medication error is weighing heavy on a weary profession.




					wpln.org
				





As a former Vanderbilt nurse awaits sentencing for a medical error, her conviction sparks widespread worry​BLAKE FARMER
APRIL 14, 2022






Mark HumphreyAP Pool Photo
RaDonda Vaught, left, with her attorney, Peter Strianse, right, was charged with reckless homicide and felony abuse of an impaired adult after a medication error killed a patient. She was convicted of the lesser charge of negligent homicide.



Listen
00:00/02:27

Share:
FacebookTwitterEmail
The name RaDonda Vaught is now well-known by nurses nationwide. She worked in critical care at Vanderbilt University Medical Center, and she awaits sentencing May 13. Her negligent homicide conviction for a medication error is weighing heavy on a weary profession.
Nurses couldn’t help but put themselves in Vaught’s place, with many saying so publicly on social media.
“I made some mistakes that … I didn’t sleep for three days,” says Katy Greene Davis, a former trauma nurse at Johns Hopkins in Baltimore, who transitioned away from the bedside a year ago.
Davis says nurses are going to be more reluctant to jump into life-and-death situations. And when mistakes happen, they’ll have every reason to clam up.
“It’s going to become us-versus-them when it has to be — for the safety of the patient — all for one and one for all,” she says.
In Vaught’s case, she mistakenly gave 75-year-old patient Charlene Murphey a powerful paralytic injection rather than a sedative with a similar name. She admitted the grievous error immediately — acknowledging all the warnings she missed along the way. Murphey died.
Vaught was initially cleared by the Tennessee Board of Nursing, but local prosecutors pressed charges. As soon as the guilty verdict was read in late March, Vaught stepped out of the courtroom and addressed nurses watching in-person and online.
“Do what you do. Do it well. And don’t let this defeat you, mentally,” she said.
The judge has wide discretion, but Vaught could face jail time. Many nurses have indicated they plan to rally outside the courthouse during sentencing. More than 200,000 have signed an online petition asking for clemency.
Her former employer has not faced punishment. Vanderbilt settled with the family and did not help with Vaught’s defense. The hospital has not commented on the case, despite repeated requests from WPLN News.
After the guilty verdict, prosecutor Chad Jackson was pressed about whether other nurses can expect criminal charges.
“This was not a case against the nursing community. This was about the actions of one individual,” he said.
The case has been used by candidates vying to replace Nashville District Attorney Glenn Funk, promising not to prosecute health care workers if elected. Funk has been defending his decision to charge Vaught since the verdict was reached, most recently on Wednesday’s This Is Nashville. He says 30 medical professionals reviewed the investigation before charges were filed and that the primary purpose was to keep her from working as a nurse ever again.
“A jury that included two medical professionals — one of whom was a nurse — convicted RaDonda Vaught,” he said. “Our job is public safety, and we wanted to make sure the public was safe and she could not continue to be a nurse.”
But the conviction piles on top of all the pandemic-related headaches and heartaches nurses have had to endure. Alyssa Brady of Roseville, Ohio, is one of the many nurses who donated to help pay Vaught’s legal fees. She also joined fellow nurses in Ohio establishing a nonprofit called Nurse Guardians. Part of its mission is to help fund legal defense for nurses who, like Vaught, may face jail time for a medical error.
“She’s just the first one to be thrown on the chopping block,” Brady says. “And it did light a fire under the nursing community. We are not going to stand for this.


----------



## Evolving78 (Apr 14, 2022)

Whatever happens, the whole clinical care system needs an overhaul! Front and back-end.


----------



## naturalgyrl5199 (Apr 14, 2022)

I don't understand some in the nursing community's response. Are they saying they want the freedom to be able to kill someone accidentally and just go home? Retire? 

What happens to OTHER nurses who have accidentally killed? What was the precedent?

I remember when Dennis Quaid's newborn twins were given 10000x the dose for a medication that almost killed them. That was in California. I remember thinking, a nurse is going to run into the wrong family who won't quit until that nurse or doctor is prosecuted. I think the DA did what needed to be done and it looks like he consulted the nursing community. Plus a nurse was on the jury.


In situations like this I always hearken to the nurses out there bending their backs to ensure things like this doesn't happen. I'm the first to say "yes, please get on my nerves!" No one will ever say quality failed.


----------



## Jmartjrmd (Apr 14, 2022)

naturalgyrl5199 said:


> I don't understand some in the nursing community's response. Are they saying they want the freedom to be able to kill someone accidentally and just go home? Retire?
> 
> What happens to OTHER nurses who have accidentally killed? What was the precedent?
> 
> ...


I can tell you they are upset about is the lack of accountability the hospital showed in this case and their multiple attempts to cover it up UNTIL another Hospital worker blew the whistle.  They failed to report this as a sentinel event.  They feel like the hospital threw her under the bus and took no responsibility in what took place to allow her to make such a huge mistake.  I personally think she had multiple chances to catch her error but also the systems in place to help her not make that kind of mistake failed.  
The problem in this case is that they worry Medical professionals, not Just nurses, will stop reporting errors in fear of being prosecuted.  Some of those errors do not have to result in death if they were reported timely enough.
And how many other pharmacists, doctors, nurses etc have made these type of errors but were not prosecuted.  I can safely say hundreds of thousands.
The TN board of nursing revoked her license in all 50 states the 2nd time they met so she can never be licended as a nurse in the US again.
Every hospital policy or 99% of them were born from errors.
Time out procedures where you stop and verify what you're doing.on which patient and to which body part came about from wrong site surgery or wrong patient procedures.
I was working at Duke when that whole incompatible lung transplant fiasco happened.

The medication scanning system was born out of wrong med, wrong patient medication errors.
Breastmilk scanning systems for the same reason.
Double checking meds with another practitioner same reason...or having the pharmacy prepare more doses rather than having nurses draw them up.

But still errors occur.  i remember catching an error on a sound alike antibiotic. The main reason i knew it was wrong was because i knew the medication they ordered is yellow and what they were sending was clear.

The reality though is we are humans and mistakes are going to be made.  It's impossible to eliminate human error.  We try to put processes in place to minimize but that requires people coming forward when they mess up.  In Medical world it's called Just culture.
As defined below
Just culture is a concept related to systems thinking which emphasizes that mistakes are generally a product of faulty organizational cultures, rather than solely brought about by the person or persons directly involved. In a just culture, after an incident, the question asked is, "What went wrong?

I'm not lost on Medical errors being deadly.  I've lost family members that way.  I'd support disciplinary action but not jail time unless it was obviously intentional.  The family didn't want her prosecuted and they settled the case with Vandy out of court.

That's what happened in my sister's case as well.  My nephews went unpunished.

I'll have to see if I can find the case of this Jamacuan nurse that made a similar error but nothing criminal happened to her.


----------



## Jmartjrmd (May 13, 2022)

Her sentence was 3 years probation.


----------



## Theresamonet (May 13, 2022)

Jmartjrmd said:


> Her sentence was 3 years probation.



Seems fair to me.


----------



## Leeda.the.Paladin (May 14, 2022)

What punitive actions are being taken against the hospital


----------

