Medication Error Learning

It looks like Radonda Vaught has been indicted on charges or reckless homicide and impaired elder abuse.
 
www.tennessean.com

Vanderbilt ex-nurse indicted on reckless homicide charge after deadly medication swap

Radonda Leanne Vaught, 35, was indicted on Friday, according to a Monday announcement from the Tennessee Bureau of Investigation.
www.tennessean.com

Sounds appropriate. My hope is that she gets convicted, gets little to no jail time, and is no longer able to work in healthcare. And the family gets millions in compensation.

It's a bad situation, and someone died because of her actions, but I don't think jail will do anything to this person, and I don't think she will make the same mistake again.
 
Terrible precedent. Yes, she errored. Revocation of licensure is appropriate. However, there was no ill intent, no malice, and although she was neglectful, it was understandable.

Criminal charges will only chill future reporting of errors and will establish precedent for punishing people for errors.
 
Criminal charges are the not the correct remedy here
 
RocketMedic said:
Terrible precedent. Yes, she errored. Revocation of licensure is appropriate. However, there was no ill intent, no malice, and although she was neglectful, it was understandable.
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I completely agree. She should lose her nursing license, and of course will be found guilty in the civil trial that is sure to come. That's plenty. Criminal charges should require intent to do harm, or at least intent to do something that you know has a high likelihood of causing harm to someone. I don't think that is in evidence here.

And if she is going to be charged criminally, I don't think Reckless Homicide is a fair charge. Assuming the following is an accurate description of the difference between the involuntary manslaughter laws in TN, then it seems that Negligent Homicide is a more accurate charge.

From FindLaw.com:

Reckless vs. Criminally Negligent Homicide

Reckless homicide and criminally negligent homicide are more loosely defined in Tennessee to address the wide variety of behaviors that could be considered beyond the realm of acceptable to the degree that the actions are criminal. One example of reckless homicide is playing Russian roulette by picking up a gun with a single bullet in it and shooting it at a friend. There's a substantial risk the friend will die. In comparison, picking up a gun you believe is empty but failed to check before shooting at your friend could be criminally negligent, as you should have looked to be sure it was empty but had no knowledge or belief that it was loaded.
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RocketMedic said:
Criminal charges will only chill future reporting of errors and will establish precedent for punishing people for errors.
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This is a really important point, as well. It isn't any coincidence that hospitals that embrace the "Just Culture" approach tend to have WAY more medication errors reported than ones that don't. Humans will always, always, always be fallible. This means that no matter how much we stress the importance of things like reading labels and "the 5 rights", we will periodically make mistakes, and unfortunately, those mistakes will occasionally have devastating consequences. The best way to minimize errors is to remove the human element as much as possible.

For instance, why would any facility allow an elderly patient to be given versed, placed supine, and not monitored? Being appropriately monitored would almost certainly have prevented this mistake from being fatal. Why was this nurse even allowed to access vecuronium, even on override? What business does a (ostensibly non-ICU trained) resource nurse have EVER pushing vec? At the very least, accessing it should require a second log-in by another RN. Why was she answering questions from an orientee while pulling meds? There are lots of policy or engineering controls that, if they had been in place, would have made such an error less likely to occur, and if it still did, less likely to be fatal.

It's also worth pointing out that medication errors resulting in serious harm or death are probably much more common than most realize. They are usually covered up, or at least not publicized. Vandy tried to cover this one up and almost got away with it. They didn't come clean until CMS found out, and then they threw this nurse under the bus, as if the system had no responsibility at all.
 
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Summit said:
Criminal charges are the not the correct remedy here
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I tend to agree, though because of all the publicity surrounding this event, that's what they're going to do. There was no ill intent, no malice, no overt criminal intent. The nurse didn't want to kill the patient. Basically, if any sort of a criminal charge should be filed, it'd be some kind of unintentional/negligent homicide.

IMHO the correct remedy should be along the lines of revocation of her license, or at least a very long suspension of it, re-training regarding medication administration, and if she's allowed to practice again as an RN, she should have a restriction on her license that she is not to handle medication without supervision if at all. The family should also be awarded significant compensation paid jointly by the nurse and by her employer because both did not have adequate safeguards in place to prevent her from overriding the Pyxis for that med. Don't get me wrong, overrides are a necessary thing in emergent situations but they should be relatively rarely used.

Where I work, there aren't many meds that I cannot override. Paralytics themselves I cannot override. There's no way to get to them directly. Our RSI kits do have paralytics (and more) in them but those are overridden as a kit and you have to break a seal on the kit itself. Those are cognitive stops... You're not doing RSI, so you don't need the kit.

The med dispensers are only as good as the programming they're given and humans do that...
 
RocketMedic said:
Terrible precedent. Yes, she errored. Revocation of licensure is appropriate. However, there was no ill intent, no malice, and although she was neglectful, it was understandable.
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just because this wasn't an intentional action doesn't mean it doesn't rise to the level of criminal.
Akulahawk said:
There was no ill intent, no malice, no overt criminal intent. The nurse didn't want to kill the patient. Basically, if any sort of a criminal charge should be filed, it'd be some kind of unintentional/negligent homicide.
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I agree, it wasn't intentional, so maybe the proper charge is unintentional/negligent homicide, not reckless.... I'll let someone with a law degree figure that out.
Remi said:
It's also worth pointing out that medication errors resulting in serious harm or death are probably much more common than most realize. They are usually covered up, or at least not publicized. Vandy tried to cover this one up and almost got away with it.
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That is likely an accurate statement, yet there is a push for more transparency in similar events (for example, PD involved shootings). Maybe they should be publicized more, and the investigation more transparent, so it doesn't look like a major cover-up?
Remi said:
They didn't come clean until CMS found out, and then they threw this nurse under the bus, as if the system had no responsibility at all.
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the "system" can put all the restrictions in place, but at the end of the day, it's the nurse's fault. Maybe the "system" needs to put more restrictions in place, to prevent people from bypassing safety systems, and existing checks, and prevent a nurse from giving a medication that she hasn't verified is the correct medication (I mean, imagine if the medication restocker dropped a vec bottle in the versed section of the Pyxis, that would also have been bad if the nurse gave it without reading the actual medication), or one of a hundred other controls that medical personnel will complain about, because this one nurse messed up in a really big way.

Using the shotgun approach (well, this person messed up royally, so now everyone needs to be more restricted and double checked and systemically enforced) is generally a bad more for employee morale. A lot of your "fixes" (from post #4) are valid, however they still require the provider to follow them. You can reinforce, you can tell them to do something, but once you provide a way for them to bypass a safety feature, and don't QA that bypass to ensure it was used appropriately, it allows for the level of complacency to occur as occurred here.

Yes, you will need to make policy adjustments, add additional controls when needed, but at the end of the day, the onus should fall on the provider to do their job to the level that they are trained to. Once they fail to do that, it's all downhill, and bad things happen. Personal accountability seems to have fallen out of favor in modern times.

But I will agree with you: the system does bear some responsibility in this.... likely 90% nurse and 10% system.
 
Dr Parasite: so should the entire periop staff of an unintentional wrong site surgery be charged with what?
Conspiracy
Assault and Battery
Mayhem/Maiming
 
i believe conspiracy requires an intentional act, assault or battery is possible, depending on consent, and I wouldn't even know what maiming/mayhem was. my legal background isn't strong enough to say for sure

but if that unintentional wrong site surgery results in the person dying on the table? Such as the right lung is not functioning and is supposed to be removed but the surgeon takes the left out by mistake? Should the entire periop staff be charged? probably not. But the provider who did the act? you'd have to ask an attorney what the criminal levels are.

what about this: an anesthesiologist gives the incorrect meds when putting a person under for routine knee surgery. but they still go unconscious. while the surgery is going on, he steps out to take a phone call and has a nurse cover him. the nurse notices the patient's vitals deteriorating, calls for the doc to notify him but he says "5 more minutes, the patient will be fine." 10 minutes later he walks in, patient is turning blue, and and doc starts screaming at the nurse. patient dies. Should that be a criminal act? a negligent act? was the death preventable? More accurately, if he had pushed the right medication, and properly monitored the patient, this likely wouldn't have happened.
 
DrParasite said:
i believe conspiracy requires an intentional act, assault or battery is possible, depending on consent, and I wouldn't even know what maiming/mayhem was. my legal background isn't strong enough to say for sure

but if that unintentional wrong site surgery results in the person dying on the table? Such as the right lung is not functioning and is supposed to be removed but the surgeon takes the left out by mistake? Should the entire periop staff be charged? probably not. But the provider who did the act? you'd have to ask an attorney what the criminal levels are.

what about this: an anesthesiologist gives the incorrect meds when putting a person under for routine knee surgery. but they still go unconscious. while the surgery is going on, he steps out to take a phone call and has a nurse cover him. the nurse notices the patient's vitals deteriorating, calls for the doc to notify him but he says "5 more minutes, the patient will be fine." 10 minutes later he walks in, patient is turning blue, and and doc starts screaming at the nurse. patient dies. Should that be a criminal act? a negligent act? was the death preventable? More accurately, if he had pushed the right medication, and properly monitored the patient, this likely wouldn't have happened.
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And they are culpable. Civil suits. Malpractice. Professional sanctions. Settlements. Public apologies. But they're not going to jail for good-faith errors.
 
DrParasite said:
Yes, you will need to make policy adjustments, add additional controls when needed, but at the end of the day, the onus should fall on the provider to do their job to the level that they are trained to. Once they fail to do that, it's all downhill, and bad things happen. Personal accountability seems to have fallen out of favor in modern times.

But I will agree with you: the system does bear some responsibility in this.... likely 90% nurse and 10% system.
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It isn't that personal accountability has fallen out of favor. Can you give an example of anyone who has suggested that this nurse shouldn't be held personally accountable?

What you are confusing for a lack of personal accountability is a recognition that the way to reduce the chance of these things happening is not to keep focusing on the obvious fact that most of the responsibility here falls on the individual who made the mistake. We all get that. But you don't prevent fallible humans from making errors just by telling them not to make errors, and punishing them when they do. We've tried that. It doesn't work.

Instead, you have to accept the fact that people will occasionally make mistakes, and find ways to compensate for that.
 
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one of the sad aspects of this was that the nurse was being observed by an 'orientee.' had the nurse viewed her situation of no pharm rx and no access in pyxsis as a teaching opportunity, the scenario could have gone like this: i have an oral order for versed, but the order isn't in the pharm pt charts yet. i'll have to override pyxis . so i can get the VERSED a mild tranquilizer from pyxis by doing an override.. i'll type in V E R S E D... then when the drug comes out i'll read the label V E R SED ...
 
Emergency Department I worked at years ago had a policy (new for the area) of reporting errors and accidents with no retaliation.
Turned out that was only true for nurses.
I made a mistake one shift where I switched 2 IV antibiotics on 2 of my patients, both antibiotics were in the 'cillin' family so they didn't hurt the patients because neither were allergic to them, and both patients were named Smith. I realized later what I did (I don't even remember how I realized it). I reported it via computer reporting system.
next shift 2 days later I was told I was being demoted to Pt care tech, $8 hr pay cut.

Same week a RN (20 years experience) gave a 3 year old pt in anaphylaxis 1mg Epi 1:1,000 "if they should only get 0.15mg" it should come that way".
2nd pt got 3 vials of Ketorolac instead of 1 vial of Ketamine (she couldn't read the doc's writing and asked someone what the dose was , and was told it would be 1 vial (she didn't ask if she should keep giving more, she just wasn't getting the expected reaction so she kept pushing more.
3rd patient we stopped her when the charge nurse from L & D called down asking why she told a nurse there to send all of their Fentanyl down (along with all of the Fentanyl from Med Surge, and Pediatrics) and was on the phone talking to pharmacy because she was looking for 50mg of Fentanyl for a patient: because it is NOT her place to question the ED doctor when she wrote orders for MG instead of MCG for Fentanyl. Even though she was being told that the hospital didn't have that much.

The ED charge nurse wrote her up and the DON of nursing told her to be more careful in the future, same day, just before I was demoted for an honest mistake that didn't hurt anyone. When I asked why it happened that way (we were both in the DON's office at the same time) I was told "your just a medic, she is a nurse" I replied at least I am a medic that isn't trying to kill his patients, unlike some nurses; and quit.

2 months later I transported a patient from that ED, to the mother hospital that the nurse had basically killed and they got ROSC back on. They let her retire for that 'mistake'.
 
This should probably be kept in the domain of licensure and civil damages.

However, I do find many in the healthcare community are trying to shift all blame onto the “system”. I find that a very troubling trend; where is the personal accountability and responsibility? People keep saying this is a “systemic failure”; I don’t think it is. Multiple safeguards were bypassed, for one reason or another. Aside from what should be routine manual validation of drug and dose, the Pyxis was overridden and the medication wasn’t scanned at any point. Either of these systemic safeguards could have prevented this tragedy. Additional institutional controls don’t work when individuals categorically ignore them, as happens routinely both in this case and in ERs everywhere. No one has explained to me how n+2 safeguards would’ve prevented this, when people already find n safeguards cumbersome, time-consuming, and not worth following.

The true “systemic” change needs to be a culture change, of following the existing safeguards every time. And I think it needs to be driven by the individual.
 
MonkeyArrow said:
This should probably be kept in the domain of licensure and civil damages.

However, I do find many in the healthcare community are trying to shift all blame onto the “system”. I find that a very troubling trend; where is the personal accountability and responsibility? People keep saying this is a “systemic failure”; I don’t think it is. Multiple safeguards were bypassed, for one reason or another. Aside from what should be routine manual validation of drug and dose, the Pyxis was overridden and the medication wasn’t scanned at any point. Either of these systemic safeguards could have prevented this tragedy. Additional institutional controls don’t work when individuals categorically ignore them, as happens routinely both in this case and in ERs everywhere. No one has explained to me how n+2 safeguards would’ve prevented this, when people already find n safeguards cumbersome, time-consuming, and not worth following.

The true “systemic” change needs to be a culture change, of following the existing safeguards every time. And I think it needs to be driven by the individual.
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From what I read it was the norm for the Pyxis not to work correctly and require a manual override. There was also no scanning function available in the unit.

Apparently this nurse has always taken full responsibility for her behavior, is contrite, and has shown empathy towards the victim and their family.

Providers are destined to make mistakes during their careers. No one is perfect, especially when working in such an imperfect system.

We need providers to immediately report mistakes and learn from them. We need a system that encourages honesty.

With the exception of intentional harm, we shouldn't be charging medical providers with criminal charges related to patient care.

How is this outcome better than a civil lawsuit?
 
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