Radonda Vaught case shows the corruption of state regulatory boards

[Proudfather94]

I've been following this case and honestly this corruption needs to be called out. This nurse accidently did a med error potentially causing a patient death. She reported the error and did all the thing she was suppose to do and was then fired. Vanderbilt swept the situation under the rug to try to avoid bad publicity. Someone made a tip to medicaid and after they threatened to cut reimbursement the nursing board who had cleared Radonda reopened the case and pulled her license and they are now charging her with reckless homicide.

The governor got campaign money from Vanderbilt and is the one who appointed people on the board of nursing. It's crazy to know that if you or a loved one gets injured or killed at a place that donated money to a campaign that you can get swept under the rug and if you work at one of these places they will go out of their way to make sure you get hit by the proverbial bus to save themselves.

This shows these boards don't even put patient safety first they care about their scratching their donors backs more.

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[Proudfather94]

Well she was found guilty. This is going to have a major impact on Healthcare.

 

[NotAProgDirector]

This is a really tough case.

For certain, mistakes happen in healthcare. And most of the time, the mistakes are due to good people making an inadvertent error due to a system failure. We try to design our systems to help people avoid making mistakes.

And that's somewhat what happened here. There were multiple system problems that allowed this error to occur. But, the nurse involved also had multiple warnings, multiple chances to stop and prevent this tragedy, but she blew through all of them.

Nurse errors I can see from quickly reviewing the story:
Looked up the med by name and chose the wrong medication.
Accudose override to get the medication out.
Accudose warning that this was a paralytic (sounds like there may have been 5 warnings)
Medication requires reconstitution, which midazolam does not.
Warning on vial cap that this is a paralytic.

Not mentioned in the story, but equally problematic:
Apparently after giving what she thought was Versed, she did not monitor the patient. The Vec would have an onset in 1-2 minutes. Giving a dose of Versed and walking away from the patient seems also unacceptable.

The system also failed multiple times here:
Accudose system was not working such that overrides were commonly needed.
Likely due to above, there was alert fatigue.
Versed used for sedation for imaging studies. There really isn't any reason to use Versed for this. An oral benzo on call for imaging works just fine and is much safer.
Vecc being in the accudose at all. Should not be there. Should be only available to anesthesia providers, usually stored in an Emergency Airway box. It would be stored in the OR's and other places where intubation occurs regularly, but not on a floor accudose.
Unclear if they have a policy regarding sedation, but IV midaz requires some monitoring, for at least 5-10 minutes.

The question is whether the nurse's lapses in this case exceed what might be expected for a typical nurse. Her explanation appears to be that she become overly complacent -- and honestly I have a problem with that. Some articles mention other similar cases -- one where a nurse almost made an error but triple checked it at the end (which is the opposite of complacency), and one where someone confused Versed with Verapamil -- which involves many less errors since the two meds are liquids, there won't be warnings, etc. This case had such egregious and numerous safety problems I am not surprised that she was found guilty, and not convinced this will lead to more prosecutions.

Overall, it's a very sad situation for everyone. I doubt Vandy walked away from this unscathed -- I'm sure there was a large financial settlement. I do agree that since Vandy tried to bury this, they seem to have gotten off much more lightly than I would expect -- although that all depends upon the law, and cutting off CMS funding would essentially put them out of business instantly which would benefit no one. I expect there were fines and penalties, and I hope Vandy learned from this and is focused on improving their systems. Once the prosecutor decided to charge here, there's nothing much Vandy can do to protect her.

 

[Proudfather94]

This is a really tough case.

For certain, mistakes happen in healthcare. And most of the time, the mistakes are due to good people making an inadvertent error due to a system failure. We try to design our systems to help people avoid making mistakes.

And that's somewhat what happened here. There were multiple system problems that allowed this error to occur. But, the nurse involved also had multiple warnings, multiple chances to stop and prevent this tragedy, but she blew through all of them.

Nurse errors I can see from quickly reviewing the story:
Looked up the med by name and chose the wrong medication.
Accudose override to get the medication out.
Accudose warning that this was a paralytic (sounds like there may have been 5 warnings)
Medication requires reconstitution, which midazolam does not.
Warning on vial cap that this is a paralytic.

Not mentioned in the story, but equally problematic:
Apparently after giving what she thought was Versed, she did not monitor the patient. The Vec would have an onset in 1-2 minutes. Giving a dose of Versed and walking away from the patient seems also unacceptable.

The system also failed multiple times here:
Accudose system was not working such that overrides were commonly needed.
Likely due to above, there was alert fatigue.
Versed used for sedation for imaging studies. There really isn't any reason to use Versed for this. An oral benzo on call for imaging works just fine and is much safer.
Vecc being in the accudose at all. Should not be there. Should be only available to anesthesia providers, usually stored in an Emergency Airway box. It would be stored in the OR's and other places where intubation occurs regularly, but not on a floor accudose.
Unclear if they have a policy regarding sedation, but IV midaz requires some monitoring, for at least 5-10 minutes.

The question is whether the nurse's lapses in this case exceed what might be expected for a typical nurse. Her explanation appears to be that she become overly complacent -- and honestly I have a problem with that. Some articles mention other similar cases -- one where a nurse almost made an error but triple checked it at the end (which is the opposite of complacency), and one where someone confused Versed with Verapamil -- which involves many less errors since the two meds are liquids, there won't be warnings, etc. This case had such egregious and numerous safety problems I am not surprised that she was found guilty, and not convinced this will lead to more prosecutions.

Overall, it's a very sad situation for everyone. I doubt Vandy walked away from this unscathed -- I'm sure there was a large financial settlement. I do agree that since Vandy tried to bury this, they seem to have gotten off much more lightly than I would expect -- although that all depends upon the law, and cutting off CMS funding would essentially put them out of business instantly which would benefit no one. I expect there were fines and penalties, and I hope Vandy learned from this and is focused on improving their systems. Once the prosecutor decided to charge here, there's nothing much Vandy can do to protect her.

I think she should have lost her license for her negligence but the criminal charge is too far. Nurses are already saying they won't report a med error until they have a lawyer present and now they are saying they won't override for medications and won't do verbal orders. This is going to get patients killed in emergencies.

Vandy set her up. The bon cleared her but when the tip to CMS got made they came back and took her license and the state prosecuted her. The governor appointed the people on the bon and got campaign money from Vandy and the DA was a prof there. Institutions using their reputations and favors to get someone thrown in jail should not be happening in this country.

According to the defenses witness Vandy didn't change anything until CMS came in a year later and made them. Their pixys machine was out in the hallway so they couldn't even draw their meds in peace.

My question is how that with this precedent that was set how far are they going to go with this? If you're a Dr and give a med that the patient is allergic too with no medical history to warn you and they die do you go to jail for manslaughter? You order moderate Si instead of high Si as you believe that the pt doesn't need a sitter and they end thereself are you going to jail?

 

[Crayola227]

I think she should have lost her license for her negligence but the criminal charge is too far. Nurses are already saying they won't report a med error until they have a lawyer present and now they are saying they won't override for medications and won't do verbal orders. This is going to get patients killed in emergencies.

Vandy set her up. The bon cleared her but when the tip to CMS got made they came back and took her license and the state prosecuted her. The governor appointed the people on the bon and got campaign money from Vandy and the DA was a prof there. Institutions using their reputations and favors to get someone thrown in jail should not be happening in this country.

According to the defenses witness Vandy didn't change anything until CMS came in a year later and made them. Their pixys machine was out in the hallway so they couldn't even draw their meds in peace.

My question is how that with this precedent that was set how far are they going to go with this? If you're a Dr and give a med that the patient is allergic too with no medical history to warn you and they die do you go to jail for manslaughter? You order moderate Si instead of high Si as you believe that the pt doesn't need a sitter and they end thereself are you going to jail?

Lol what your last two examples are not at all like this case. Those errors are easy to make. This was extreme negligence.

 

[NotAProgDirector]

Vandy trying to bury/hide this was unacceptable. We totally agree there.

You seem to be assuming that what happened was that after CMS found the error, that Vandy blamed it all upon the nurse to avoid punishment / make CMS happy. It's much more likely that Vandy fired her and buried the case to avoid this exact outcome, trying to protect her (and themselves). I think the state prosecuted her because the evidence was such that this rose to the level of severe negligence. I doubt that Vandy wanted her prosecuted -- this only brings more bad press to them and more focus / reporting on the issue.

Whether or not she admitted to an error is (almost) immaterial. If she had kept completely quiet, there would be some chance that the error would never have been found -- it's unclear if Vandy would have done an investigation. Had it be found and she denied / lied about it, then she would have ended up being found guilty of the higher charge. The fact that she showed remorse likely helped her.

Vandy "not changing anything until CMS arrived" is extremely poor on their part. Every time we have a sentinel event -- including near misses -- we do a deep dive, try to find any problems we can fix, and fix them. Hopefully Vandy has changed their process.

Nurses refusing to override the Pyxis is a good thing. Vandy should fix their system so overrides are not needed. In the very rare cases where they might be needed, nurses can then really focus on making sure they are doing the right thing. Refusing verbal orders is also a good thing (perhaps except in rare emergencies). Nurses refusing to report a med error without a lawyer present isn't actually possible -- you can't bring a lawyer to work, and if reporting errors is part of hospital policy and then you don't you can be fired for even a small error for not reporting it. Plus, by not reporting errors nurses are just making it worse by not allowing Vandy to fix things.

 

[Proudfather94]

Vandy trying to bury/hide this was unacceptable. We totally agree there.

You seem to be assuming that what happened was that after CMS found the error, that Vandy blamed it all upon the nurse to avoid punishment / make CMS happy. It's much more likely that Vandy fired her and buried the case to avoid this exact outcome, trying to protect her (and themselves). I think the state prosecuted her because the evidence was such that this rose to the level of severe negligence. I doubt that Vandy wanted her prosecuted -- this only brings more bad press to them and more focus / reporting on the issue.

Whether or not she admitted to an error is (almost) immaterial. If she had kept completely quiet, there would be some chance that the error would never have been found -- it's unclear if Vandy would have done an investigation. Had it be found and she denied / lied about it, then she would have ended up being found guilty of the higher charge. The fact that she showed remorse likely helped her.

Vandy "not changing anything until CMS arrived" is extremely poor on their part. Every time we have a sentinel event -- including near misses -- we do a deep dive, try to find any problems we can fix, and fix them. Hopefully Vandy has changed their process.

Nurses refusing to override the Pyxis is a good thing. Vandy should fix their system so overrides are not needed. In the very rare cases where they might be needed, nurses can then really focus on making sure they are doing the right thing. Refusing verbal orders is also a good thing (perhaps except in rare emergencies). Nurses refusing to report a med error without a lawyer present isn't actually possible -- you can't bring a lawyer to work, and if reporting errors is part of hospital policy and then you don't you can be fired for even a small error for not reporting it. Plus, by not reporting errors nurses are just making it worse by not allowing Vandy to fix things.

I do think she was negligent and needed her license revoked, but I think Vandy takes enough of the responsibility to not charge her criminally. If there was a possibility of scanning the vec and she just chose not to and gave it or if she did scan it and it said it was the wrong med and she gave it anyway she would deserve to be charged.

 

[Proudfather94]

Lol what your last two examples are not at all like this case. Those errors are easy to make. This was extreme negligence.

It was but it wasn't like things were set up for her to easily do her job. This case set the ground work to charge healthcare workers for bad outcomes they don't need to be this negligent to convince a DA to press charges now.

 

[NotAProgDirector]

As I mentioned to start, this is a very difficult situation. There's no question that Vandy is at fault here and that this is primarily a system error. The question, which is hard to assess from the vague details in the news, is how many in-place safety protocols the nurse bypassed. For example, the BCMA - Bar code med administration. If they had scanning of meds to check, and she just skipped it -- that's a huge problem. If the BCMA wasn't set up, or if it was unavailable where the patient was located, then that's more of a system problem. So much depends on how many steps were skipped / bypassed because the nurse chose to do so.

 

[Proudfather94]

As I mentioned to start, this is a very difficult situation. There's no question that Vandy is at fault here and that this is primarily a system error. The question, which is hard to assess from the vague details in the news, is how many in-place safety protocols the nurse bypassed. For example, the BCMA - Bar code med administration. If they had scanning of meds to check, and she just skipped it -- that's a huge problem. If the BCMA wasn't set up, or if it was unavailable where the patient was located, then that's more of a system problem. So much depends on how many steps were skipped / bypassed because the nurse chose to do so.

From what I heard the pt was getting some kind of scan done and the floor they were on did not have scanners.

 

[deleted1100659]

Lol what your last two examples are not at all like this case. Those errors are easy to make. This was extreme negligence.

I think that her punishment seems harsh to me but I agree I still don't completely understand how that error happened, I mean that's a pretty big error. Was she overworked or sleep deprived? But even then, ive did my fair share of >24 hour shifts in residency and I still verified meds on the MAR.

maybe too harsh of a punishment, but what a weird mistake to make.

Its like someone coming to me for anxiety, and I order clozapine 300mg BID.

 

[SurfingDoctor]

Vandy was *****ic with terrible administration AND the nurse made a series negligent of mistakes. Together these resulted in a patient death.

Of course, Vandy has more money to protect itself and let the person who made the mistakes burn in the fire without even feeling an ember. Welcome to corporate healthcare.

 

[nikolaite]

It was but it wasn't like things were set up for her to easily do her job. This case set the ground work to charge healthcare workers for bad outcomes they don't need to be this negligent to convince a DA to press charges now.

It was not that the patient died in the course of standard care which was tested in this legal case. It was that this particular nurse killed her patient. So you start from the same point of the case of the nurse injecting newborns with insulin with the direct intent to cause death and roll back a bit to Vaught. Vaught did not apparently intend this patient’s death. Vaught also did not intend standard care: she bypassed roughly 17 protocols of the nursing field, and specific hospital policy on patient safety. Basically, this was not a matter of inadvertent bad outcome, but bad input in the face of many opportunities for beneficence causing a foreseeable bad outcome. It was the worst kind of negligence as it caused a disabled woman to die a horrible death.

The Board of Nursing opened their original investigation based on a what is called an individual complaint of violations. These rarely resolve against the favor of the provider being investigated because colleagues will close ranks and Risk Management depts will snatch patient protected health information up and send it to legal as attorney-client work product to hide it from medmal attorneys and state investigators. In those cases, there is no way to investigate the matter and the complaints get closed, but kept on file for future use. The only reason the board reopened Vaught’s case is that a whistleblower turned over documentation of violations to CMS that the Nursing Board was able to get ahold of.

Nursing associations are making this out to be a precedent-setter whereby nurses and others by extension can be charged criminally for bad outcomes in the course of standard care. That’s not what the Vaught case is about. That’s self-serving marketing hype to protect corporate medical systems from having to provide safe medical centers and decent working conditions. It makes these nursing associations sound a bit psycho, in using Vaught suggests that nurses ought to be free from societal strictures to snuff a patient every so often.

Vaught testified to the board that she was not tired, overworked or hassled, just complacent with the way things were done.

…and a patient got to ride an aware Vec paralysis into the great beyond…

 

[Nephro critical care]

Nurses make exit plans after RaDonda Vaught's conviction

More than 100,000 nurses left the workforce in 2021, according to an analysis published April 13 in Health Affairs. Now a nurse's criminal conviction for a medical error has the profession worried about how that number might swell.

www.beckershospitalreview.com

Good job making the bedside nurse staffing crisis much worse than it already was. Our ICU has had to go from 2 to 3-4 critically ill pts per nurse. Really improved pt care !

 

[emergentmd]

Terrible Case. I have seen worse from Docs and RNs who do not lose their license. She was made a scapegoat by the hospital system.

I override my ordering system all the time b/c it pops up the most insane interactions.

Pts die all the time from med errors, and poor judgement. How is this even a criminal case?

 

[VA Hopeful Dr]

Terrible Case. I have seen worse from Docs and RNs who do not lose their license. She was made a scapegoat by the hospital system.

I override my ordering system all the time b/c it pops up the most insane interactions.

Pts die all the time from med errors, and poor judgement. How is this even a criminal case?

You have seen worse than this? The patient was awake and suffocated to death. There are very few deaths that I can imagine happening in a hospital that are worse than this.

 

[emergentmd]

You have seen worse than this? The patient was awake and suffocated to death. There are very few deaths that I can imagine happening in a hospital that are worse than this.

Outcome and result was bad. Intent was a mistake that are made in medicine and happens due to multifactorial. This is clear malpractice, but no way is this a felony. If this is case law for a criminal verdict, then you can make a case for everyone who is injured with inadvertent med errors.

I have been part of MEC reviewing docs doing surgery/clinical care intoxicated, unnecessary procedures just to bill the insurance, ordering non standard of care meds, ordering wrong meds, etc.

So if a doc clicked on Vecuronium instead of Valium, pt dies, then he and the inexperienced nurse should go to jail?

 

[VA Hopeful Dr]

Outcome and result was bad. Intent was a mistake that are made in medicine and happens due to multifactorial. This is clear malpractice, but no way is this a felony. If this is case law for a criminal verdict, then you can make a case for everyone who is injured with inadvertent med errors.

I have been part of MEC reviewing docs doing surgery/clinical care intoxicated, unnecessary procedures just to bill the insurance, ordering non standard of care meds, ordering wrong meds, etc.

So if a doc clicked on Vecuronium instead of Valium, pt dies, then he and the inexperienced nurse should go to jail?

Intent wasn't the issue here, otherwise she'd have been charged with murder.

She gave a medicine that directly killed a patient. This wasn't a case of a medication that had a bad side effect or interacted with something else (contrast with tpa causing a brain bleed). This medicine directly killed him. A medication that wasn't supposed to be given in the first place. After overriding multiple safety warnings. Then just left the patient alone and unmonitored, which probably shouldn't have happened even had she given the correct medicine (versed).

 

[Nephro critical care]

Why nurses are raging and quitting after the RaDonda Vaught verdict • Tennessee Lookout

The American Nurses Association and the American Association of Critical-Care Nurses warn the RaDonda Vaught verdict sets a risky precedent.

tennesseelookout.com

Most of our ICU nurses have quit over the last 2 years. We first hired travellers but then it became too expensive so now we got inexperienced baby nurses. One of them gave antihypertensives to a pt on pressors because BP was 110 and she didn’t know better. For 24 hrs I was dealing with the effect of the antihypertensives. I mentioned this to the ICU nursing director and she counselled the nurse. Maybe I should have reported to the nursing board and got her license taken away and also reported to police so they could come and take that nurse away handcuffed from ICU for incompetence and endangering a patient.
I guarantee you if I did that we wouldn’t have any nurses the next day to work in our ICU.

 

[Nephro critical care]

I always felt that nurses are paid a pittance for a very hard and responsible job. In my ICU nurses start out at $28/hr which is not that much above minimum wage. COVID made it a little better for a while but now other than travellers most are back to working for peanuts. My wife was getting $17 an hour for home care for 40 hrs a week just to take care of our developmentally delayed son.
Why would anyone want to be a nurse taking care of 3 critically ill patients at a time for $28/hr if they are breaking their backs for q2hrs turning , are constantly charting and if they get overwhelmed and screw up they run the risk of losing their license and getting hauled off to jail. If a fast food restaurant worker screws up they will at most get an irate customer; not jail time.

 

[wholeheartedly]

Outcome and result was bad. Intent was a mistake that are made in medicine and happens due to multifactorial. This is clear malpractice, but no way is this a felony. If this is case law for a criminal verdict, then you can make a case for everyone who is injured with inadvertent med errors.

I have been part of MEC reviewing docs doing surgery/clinical care intoxicated, unnecessary procedures just to bill the insurance, ordering non standard of care meds, ordering wrong meds, etc.

So if a doc clicked on Vecuronium instead of Valium, pt dies, then he and the inexperienced nurse should go to jail?

That is exactly what negligent homicide is for. Negligent homicide is homicide that wasn’t intended but happened due to being reckless. This absolutely fits.

Please research this case beyond the surface level stuff being reported. There are extensive, detailed documents available that show this wasn’t an just oops, simple mistake anyone could make.

People are acting like this is the negligence equivalent of someone driving 5 mph over the speed limit and hitting and killing someone because they glanced the other direction for a second. But this scenario, when you read all of the actual details, show’s it’s more like driving 20 over the speed limit while eating and face timing while driving and killing someone as a result level negligence.

I worked in healthcare for like 15 years and served on several variations of event mgmt and root cause analysis review type groups. I’ve seen lots of bad things that have happened but I never once saw a single individual blow through so many basic level safety protocols and checks in one pt care episode, most of which did not rely on a computer system. These were nursing 101 things.

 

[emergentmd]

That is exactly what negligent homicide is for. Negligent homicide is homicide that wasn’t intended but happened due to being reckless. This absolutely fits.

I agree with the definition but I do not agree that it applies to medicine. If you apply common law to medicine, then many doctors/nurses would be in jail.

Doc operates on wrong side - Assault
ER doc misses an obvious PE - Negligent Homicide?
Pediatrician misses obvious meningitis - Negligent homicide?
Nursing home staff too busy to take care of 10 pts by themselves and doesn't attend to a dying pt - Negligent homicide and elderly abuse?

If you are or will be a doc, if you apply common law to medicine, an aggressive DA could throw half of us in jail. I have been in alot of QA cases where the doc/nurse made negligent decisions and could easily been tried for assault/negligent homicide. If you actually believe this is negligent homicide, I hope you are not ever on the other end of an aggressive DA who is trying to make a name for himself and puts you in jail for mistakes that happens in medicine.

 

[NotAProgDirector]

What's difficult about this case is that it's a matter of extremes. Everyone agrees she didn't intend to cause this patient's death. But was this just a medical error with a bad outcome? Or was it poor nursing to an extreme that it's negligent? That's the question.

Let's take your first example - Doc operates on wrong side. I assume that all/most OR's now require that the site be marked in a way that ensures that the procedure occur on the correct side. Then, there's a time out prior to the procedure where everyone confirms the side and the patient. So, let's look at the following scenarios that result in wrong side surgery:

1. Patient is marked correctly, but was marked on the other side for a different procedure. Wrong side is picked (has a mark), not noticed in time out.
2. Patient is marked incorrectly. Wrong side is picked. No one notices during time out.
3. No side is marked. Surgeon decides OR schedule is busy, patient needs procedure, continues anyway. Not noticed in time out.
4. Wrong side is picked (choose any of the above). Someone points out during time out there is a disprepancy. Surgeon proceeds anyway, says they are certain they are on the right side.
5. Wrong side is picked. Noted in time out. Surgeon tells nurse to shut up. Nurse demands surgeon stop. Surgeon throws surgical tool at nurse who runs from OR. Surgeon operates.


There is no clear line between medical error and gross negligence. To me, #1 is a medical error - clearly demonstrates that the marking must be unique (we use the surgeon's initials, plus a date I think). #5 is negligence (and perhaps assault against the nurse also...). The rest I expect there would be some disagreement about (and perhaps #1 and #5 also).

Does the Vaught story reach the level of negligence? She made so many errors, one after another, and took shortcuts. But the system clearly failed also. For me, much would depend upon whether she was an outlier or not -- if all nurses/processes at Vandy were this sloppy then Id put the blame on Vandy. If not, then I think she is responsible.

 

[emergentmd]

Some may disagree but I feel you can not apply common law to certain professions unless there was intent to harm. Just can't do it otherwise the job would be impossible to perform. We deal with pts lives and mistakes kill. If you are an accountant and missed a decimal, no one dies.

I just feel medicine along with police/military are said professions.

 

[NotAProgDirector]

Some may disagree but I feel you can not apply common law to certain professions unless there was intent to harm. Just can't do it otherwise the job would be impossible to perform. We deal with pts lives and mistakes kill. If you are an accountant and missed a decimal, no one dies.

I just feel medicine along with police/military are said professions.

I can see your viewpoint, and I agree it's complicated. I think everyone agrees that if there's actual intent to harm, that's a crime. The grey area is gross negligence -- no intent to harm, but behavior that's enough out of the standard that the person should know that the chances of someone getting unintentionally harmed is unacceptably high.

Let's use police as an example. It's clear that the police can speed and run through lights to chase a fleeing criminal / respond to an emergency. Imagine the case where police are called about a more minor crime -- shoplifting or something similar. A police officer decides to respond and speeds through a red light. Hitting someone and killing them. They certainly had no intent to do so. Yet, speeding through a red light to respond to shoplifting seems unacceptably excessive to me. Imagine the person killed is someone important to you. Would you be OK with 1) no punishment, stuff just happens, 2) person loses job no longer can be police, 3) prosecuted for a crime?

Now imagine same scenario, partner told them repeatedly to slow down and they refused, "I wanna get this guy!"

 

[Nephro critical care]

She sounds very remorseful. Admits she made a mistake. Only problem is in America there is no acceptance that in the end we are humans and can get distracted ; can be tired : can sometimes make errors.

 

[VA Hopeful Dr]

She sounds very remorseful. Admits she made a mistake. Only problem is in America there is no acceptance that in the end we are humans and can get distracted ; can be tired : can sometimes make errors.

I would hope she's remorseful, she actively killed someone.

Everything depends on the results of the error. If I fall asleep at the wheel and hit a lamp post, almost no one will care. If I fall asleep at the wheel and side swipe a pedestrian who gets up and is fine, very few people will care. If I fall asleep at the wheel run into another car and the family of four in it dies, a lot of people will care.

 

[Nephro critical care]

I would hope she's remorseful, she actively killed someone.

Everything depends on the results of the error. If I fall asleep at the wheel and hit a lamp post, almost no one will care. If I fall asleep at the wheel and side swipe a pedestrian who gets up and is fine, very few people will care. If I fall asleep at the wheel run into another car and the family of four in it dies, a lot of people will care.

But it should not depend upon the result of the error. It should depend upon the intent. Lot of hospital CEO/CNO/CFOs/administrators cut nursing staffing over the last 5 years. And that was just to inflate hospital profits because the administrators salary/bonuses depended upon the hospital's bottom line. Now once the pandemic hit nurses got burnt out and quit and now we have a huge nursing staffing shortage.

Are we going to prosecute/ jail these CEOs because they deliberately cut staffing to inflate their own pockets ?

 

[VA Hopeful Dr]

But it should not depend upon the result of the error. It should depend upon the intent. Lot of hospital CEO/CNO/CFOs/administrators cut nursing staffing over the last 5 years. And that was just to inflate hospital profits because the administrators salary/bonuses depended upon the hospital's bottom line. Now once the pandemic hit nurses got burnt out and quit and now we have a huge nursing staffing shortage.

Are we going to prosecute/ jail these CEOs because they deliberately cut staffing to inflate their own pockets ?

I would be 100% behind that

 

[emergentmd]

I can see your viewpoint, and I agree it's complicated. I think everyone agrees that if there's actual intent to harm, that's a crime. The grey area is gross negligence -- no intent to harm, but behavior that's enough out of the standard that the person should know that the chances of someone getting unintentionally harmed is unacceptably high.

Let's use police as an example. It's clear that the police can speed and run through lights to chase a fleeing criminal / respond to an emergency. Imagine the case where police are called about a more minor crime -- shoplifting or something similar. A police officer decides to respond and speeds through a red light. Hitting someone and killing them. They certainly had no intent to do so. Yet, speeding through a red light to respond to shoplifting seems unacceptably excessive to me. Imagine the person killed is someone important to you. Would you be OK with 1) no punishment, stuff just happens, 2) person loses job no longer can be police, 3) prosecuted for a crime?

Now imagine same scenario, partner told them repeatedly to slow down and they refused, "I wanna get this guy!"

I get what she did was wrong and a huge mistake. Some would even say she was negligent beyond reason.

Take her case, and she is tried for murder.

How about all of the plastic surgery centers where the ones administering anesthesia are CRNA only, Non boarded docs like FM, OB, ER, etc. Or many of the dentist offices that use moderate sedation meds for procedures. Pt dies and you almost never see criminal charges.

I feel these docs who are intentionally doing moderate/deep sedation knowing they are not capable of managing complications with potential death are more criminally negligent than what she did. I would say what these surg centers are doing would be akin to her intentionally giving a paralytic but she didn't.

 

[VA Hopeful Dr]

I get what she did was wrong and a huge mistake. Some would even say she was negligent beyond reason.

Take her case, and she is tried for murder.

How about all of the plastic surgery centers where the ones administering anesthesia are CRNA only, Non boarded docs like FM, OB, ER, etc. Or many of the dentist offices that use moderate sedation meds for procedures. Pt dies and you almost never see criminal charges.

I feel these docs who are intentionally doing moderate/deep sedation knowing they are not capable of managing complications with potential death are more criminally negligent than what she did. I would say what these surg centers are doing would be akin to her intentionally giving a paralytic but she didn't.

I'd be OK with them going to jail too.

 

[NotAProgDirector]

I get what she did was wrong and a huge mistake. Some would even say she was negligent beyond reason.

Take her case, and she is tried for murder.

How about all of the plastic surgery centers where the ones administering anesthesia are CRNA only, Non boarded docs like FM, OB, ER, etc. Or many of the dentist offices that use moderate sedation meds for procedures. Pt dies and you almost never see criminal charges.

I feel these docs who are intentionally doing moderate/deep sedation knowing they are not capable of managing complications with potential death are more criminally negligent than what she did. I would say what these surg centers are doing would be akin to her intentionally giving a paralytic but she didn't.

This is a great example to also consider.

I agree that people who perform conscious sedation with inadequate training / safety protocols should also be examined closely. It would depend (for me) on how much training the person had, what the safety protocols were, equipment, and more. It's difficult to decide who is "more negligent", but I certainly agree that these cases are similar and one would expect similar outcomes - if the providers were truly being negligent.

I also agree that the decision to bring charges is highly political. It's completely up to the prosecutors / AG's office whom will get charged and tried, and that is going to depend on many aspects of the situation that honestly shouldn't be considered -- public outcry, political connections of the major players, political aspirations of the prosecutor's office, etc. It's unfair. It's a failing of our legal system.

But, if we're going to use "intent" as the yardstick, then these docs doing sedation also get a free pass. They didn't intend anyone to get killed. They were just doing what they do, and things went wrong. We can then put the immediate steps after things go bad under the microscope - how quickly did they call for help, etc -- but that's just negligence still.

That's the problem. There are routine medical errors -- despite everyone trying to do their jobs correctly an error gets made. And there's negligence -- people bypassing safety systems put in place to prevent errors, or being sloppy, etc. And then there's actual intent to harm. It's a broad spectrum, and we have no good way to decide when something is "mostly a system error" and we should address it as that, or "mostly a person error". And when bad environments encourage sloppy work -- it's even more murky.

 

[emergentmd]

Everything depends on the results of the error. If I fall asleep at the wheel and hit a lamp post, almost no one will care. If I fall asleep at the wheel and side swipe a pedestrian who gets up and is fine, very few people will care. If I fall asleep at the wheel run into another car and the family of four in it dies, a lot of people will care.

Results does affect consequences in every aspect of life. I remember doing 120 hrs a wk as an intern and there were a few times that I was sooooo tired that i literally fell asleep next to a pt I was pushing down to radiology waiting for a CT chest PE protocol. I woke up and continued to wait for my turn. Pt did fine but if they died b/c I fell asleep from a PE and it could be viewed as Gross negligent falling a sleep monitoring a critical pt.

I am glad pt did fine and I was not made an example by some DA looking for advancement..

 

[allantois]

I am not actually sure her license should be permanently suspended - sure that's a nice scapegoat, but surely she could still practice some kind of nursing safely? or be put on some kind of remediation

 

[VA Hopeful Dr]

Results does affect consequences in every aspect of life. I remember doing 120 hrs a wk as an intern and there were a few times that I was sooooo tired that i literally fell asleep next to a pt I was pushing down to radiology waiting for a CT chest PE protocol. I woke up and continued to wait for my turn. Pt did fine but if they died b/c I fell asleep from a PE and it could be viewed as Gross negligent falling a sleep monitoring a critical pt.

I am glad pt did fine and I was not made an example by some DA looking for advancement..

You're an intern, even ignoring the work hour issue (which did get changed after a death due to fatigued trainees) you're not supposed to be unsupervised so unless you actively kill someone as a direct result of something you do without consulting anyone else you're protected.

Had the nurse in question called the attending and said "this vial says vercuronium, that's the same as versed right?" and was told it was OK to give it, she wouldn't be in this much trouble.

 

[Mad Jack]

As I mentioned to start, this is a very difficult situation. There's no question that Vandy is at fault here and that this is primarily a system error. The question, which is hard to assess from the vague details in the news, is how many in-place safety protocols the nurse bypassed. For example, the BCMA - Bar code med administration. If they had scanning of meds to check, and she just skipped it -- that's a huge problem. If the BCMA wasn't set up, or if it was unavailable where the patient was located, then that's more of a system problem. So much depends on how many steps were skipped / bypassed because the nurse chose to do so.

Going to +1 this thought. Without the specifics it is very hard to say. Overriding the barcode system is a serious error and would merit negligent homicide, but anything short of that I would likely say is a systems issue

 

[NotAProgDirector]

I'm not sure I agree that "everything short of that is a systems error". If I remember the details correctly, this patient was given the med in Radiology, where BCMA wasn't available. But, did she need to get the med on the floor? In that case, she could have scanned med/patient on the floor before leaving, if she thought it likely she would need to give it.

But there are other steps here that were under the nurse's control that seem very concerning, beyond a "systems" problem:

1. The med bottle is clearly labeled right on the top that it's a paralytic. She would have had to push a needle right into that cap, staring at it, and ignore it.
2. Even if she thought it was Versed, she gave it and walked away from the patient, without further monitoring.
3. I believe she had to click through multiple warnings on the med cart to get the medication, all of them warning it was a paralytic.

But there were clear systems issues also:
1. Paralytics should NOT be in general med stock.
2. Their frequent use of overrides is unaccetpable.
3. Docs should not be ordering IV versed for radiology sedation. An oral benzo given 30 minutes before would be fine.

 

[xffan624]

I'm not sure I agree that "everything short of that is a systems error". If I remember the details correctly, this patient was given the med in Radiology, where BCMA wasn't available. But, did she need to get the med on the floor? In that case, she could have scanned med/patient on the floor before leaving, if she thought it likely she would need to give it.

But there are other steps here that were under the nurse's control that seem very concerning, beyond a "systems" problem:

1. The med bottle is clearly labeled right on the top that it's a paralytic. She would have had to push a needle right into that cap, staring at it, and ignore it.
2. Even if she thought it was Versed, she gave it and walked away from the patient, without further monitoring.
3. I believe she had to click through multiple warnings on the med cart to get the medication, all of them warning it was a paralytic.

But there were clear systems issues also:
1. Paralytics should NOT be in general med stock.
2. Their frequent use of overrides is unaccetpable.
3. Docs should not be ordering IV versed for radiology sedation. An oral benzo given 30 minutes before would be fine.

This is a picture of the warning on the vial. She also also had to reconstitute the powder vecuronium (which is not required for versed).