I am a nurse and I am kind of confused why a paralyzing agent would be in a Pyxis machine in the first place. This type of med is used for intubation and regular staff nurses don’t do that procedure. If the hospital would have kept these meds locked away and only certain staff would have access to it, then this never would have happened. The hospital and medical examiner should also be prosecuted because they both covered up the error which is negligence on their part. Since the hospital has all the money and they never seem to punish doctors when they make mistakes, the nurse ends up taking the fall for the entire incident. And I heard that she was helping out another nurse when this error happened, maybe if hospitals and nursing homes had safe nurse to patient ratios, med errors would be reduced and lives would be saved. Just my thoughts.
This is a system error! He showed the lid too on a tiny valve like anyone could see that!!! This nurse was training another nurse at the time too! There was too much risk in this case! The system failed her!
@@PurposelyObtuse when I was a nurse working inpatient psych there was almost a med error with clonidine where the doctor misplaced the decimal point and the nurse almost gave a patient 2 mg instead of 0.2 mg. Another nurse caught the error but the original nurse almost gave it even with a big red alert on the Pyxis drawer. I no longer work with patients because hospitals risk nurses licenses and patients’ lives everyday with overworking nurses and having unsafe nurse to patient ratios. I would rather sit behind a desk and not risk the license I worked very hard for. People that judge nurses for making mistakes never worked a 12 hour shift with a high work load. When people are overworked and extremely tired, they make mistakes. Hospitals know this but they fail to put things in place to make sure things like this don’t happen. And they end up throwing the nurse under the bus to take the fall. It is truly a sad situation. And they wonder why nurses are leaving the bedside.
They put nurses in a position to fail. They make sure nurses take all the risks so they can avoid any legal ramifications (if anything goes wrong they blame the nurses).
My husband (a former USAF medic and a one time nursing student) and our friend (a former USAF medic and current nurse) were literally talking about the 5Rs last night. They both had them drilled into their heads in the first weeks of nursing. My husband, even though not having completed nursing school and having learned it over a decade ago, still has it memorized. This case hits a bit close to home for him as if he hadn't questioned what antibiotic a nurse was about to give me while I was asleep post delivery, I would be dead. The nurse never checked the bright red allergy band on my wrist and almost gave me a drug that would have sent me into anaphylaxis. Too many people skip safety in favor of speed.
This is a lesson that all people can make mistakes and criminal prosecution will make healthcare less safe. Why tell the truth if you can go to prison? Just Culture.
@@janiesmys461 this was beyond a mistake. This was her criminally ignoring her training. This was not just a lack of professionalism, this was negligence on a lethal scale. Giving an incorrect dose is a mistake. Giving a medication that comes in a completely different form, has warning labels, and failing to do the most basic steps of your training goes beyond an error. If a medical professional is so worried that they do their job so badly they could be criminally liable than they shouldn't be in the medical field.
I'm a nurse. This case disturbs me, makes me think. Cases like this can make me consider my own practice in a critical fashion. The idea of "missing something" has always given me pause, and I'm sure it makes other healthcare workers think twice and thrice. Maybe that's the only good part of cases like this - if you let them, they can make health care workers examine themselves, and perhaps avoid future mistakes. When I heard of this case, my first thought was, didn't Radonda monitor the patient's reaction to the drug after she gave it? Couldn't she tell the patient's vital signs indicated increasing distress? Versed's not something you administer, then walk away for half an hour. You monitor the patient, for God's sake. Sedated people are extremely vulnerable. Hard to say how and why the patient went unmonitored. Bad practice? Distraction? Overwork? Complacency? I suspect there's more to the story. Vanderbilt Hospital's hiding what happened doesn't surprise me one bit. It's partly an outcome of the idea that a hospital should be run on a "business model" (@@) rather than as a health care center. There's also this myth that healthcare can "take care of its own" including its own bad actors. In my opinion, it cannot police itself, at least not entirely. I'm sad for the patient and for her family. The patient's death must have been awful. I'm conflicted about Radonda. Usually when big medical mistakes happen, they don't happen in a vacuum. They are an outgrowth of a wilderness of error, combined perhaps with increased-on-chronic personal stress. The stakes are high in healthcare. It's extremely important for healthcare workers to be in environments that monitor for distracted, overwhelmed workers and that honestly encourage telling the truth about mistakes.
Radonda was floating that day, taking a patient to MRI, had an orientee with her. She was like a transport nurse that day. She gave the Vecoronium and left the patient in MRI where there was a delay getting the patient in the scanner. I agree this was an ICU patient, we always had to monitor ours during transfers. System errors caused this death from the Pixis override to leaving a sedated patient. Their policies were to blame.
Thank you so much for your insight and professional experience and explanation. Anytime I got Versed was prior to a surgical procedure and was monitored carefully. My heart goes out to this poor woman's family. My niece went to med school at Vanderbilt, and has always been thought of as top notch.
@@purplgrits7916 I understand. Policies and work environment set these situations up to happen. I believe that 100%. I hear you. But in the moment, boots-on-the-ground caregivers like nurses must make decisions regardless of policy to protect themselves and their patients. Let this case be an example of the wisdom of taking a stand that policy be damned, I'm monitoring my sedated patient, and if the pencil-necks in the board rooms have a problem with it, let them fire me, I'll find a nursing job elsewhere and good riddance to them for me. I know it's a scary thing to think about - standing up to the wigs and risking your job, risking your paycheck needed to support yourself and your loved ones, but it's a must sometimes. And I've found that when as a nurse I honestly talk sense to my coworkers and to my superiors, I don't get fired, I get listened to. I'm not attacking Daronda. She'll suffer the consequences of her actions and I don't need to add to that. I'm willing to guess that the patient was unmonitored at least partly because of staffing pressures and assorted issues. That's sad. As for putting nurses in situations where they have to override the pyxis, Vanderbilt should go down for that. They knew the nurses were doing it therefore they were responsible. And as for nurses being held criminally liable, I'm okay with that, particularly in extreme cases. However, where the hell is Vanderbilt's criminal liability? If anything, Vanderbilt's policies, if they led or contributed to a death, how could they not be liable? Vanderbilt's responsibility here, you could argue, is wider and more far-reaching than Daronda's. I'm unaware of the details of the case, but is Vanderbilt being held criminally liable? Are the policy makers in need of criminal defense attorneys? I think we'll see safer policies when we start holding the wigs criminally responsible, too, not just the nurses. I keep going back to the problem of business-model healthcare. It needs to stop. As does the faulty notion that healthcare can police itself. It obviously can't. And if nurses are to be held criminally responsible in disastrous cases, hold the hospital responsible, too.
There are some serious problems in our healthcare system. While Redonda made a series of grave errors, the hospitals actions afterward are reprehensible and almost guarantees this will happen again. I want to see them punished but feel it is unlikely.
I don’t trust hospitals, especially after c19 happens. They don’t have the care they always had and are tired and overworked and don’t like people coming in for “a cold”
Why were not two nurss checking the medication against the doctor's order before it was administrated to the patient? It was a tranquilising drug that should have been checked by two nurses,the mistake would have been noticed then and the proper drug administrated.
@@yvettevernet4759 Absolutely agree. The industry I work in regularly implements a two party buy off for inspection points that are not at all life threatening. I would think this has to do with hospital policy. I also wonder if part of the series of mistakes Redonda made were related to stress, overwork and exhaustion. That is something I regularly see everywhere now.
@@jen30551 Could be that she was stressed but if the policy of two nurses checking a drug that would be administrated intraveinously as a tranquiliser had been implemented this terrible mistake would no have occured.
I think you left some parts out. #1 Radanda was a new nurse of only 2 years yet was already training another new nurse.#2 The area where the medication was given did not have a scanner#3 It was not hospital policy to stay with a patient who had been given a medication like the one ordered. #4 She didn't leave the patient alone, she left the patient with the technicians, and they told her it was fine. #5 The dose she gave may not have even been lethal, and due to the cover up by the hospital no autopsy was done. They tried to prove she gave more than she admitted to by using evidence that the hospital (the hospital that lied continually) had kept for a year before authorities took it into their possession. Anything could have been done to the evidence during that time.
Your #5 point is one that I considered: the dose for Vecuronium is 0.1mg/kg, now a lot of assumptions have to take place here, but assuming she did her due diligence and gave 2 mg Vec instead of 2 mg Versed (a common sedative dose) the amount given wouldn't be therapeutic to achieve paralysis, at least not completely, as this would have been a dose for a person weighing about 45 lbs. Despite even that, so much went wrong here, and a life was lost, tragically...
Hospitals have nurses with a few months experience training nurses. Scanner does not matter. Meds are supposed to be read with human eyes whether scanned or not.
@@ronn68 New nurses should absolutely not be training new nurses. That is dangerous. Human eyes fail. Also, why are people acting like she made a conscious choice to not check the med? I've written a paper and proofread it only to find several typos the next day. Why? Because your brain fills in the gaps. How many times have you left the house and thought you left something plugged in? How many times were you right? Or, have you done that same task so many times you went on auto pilot and that's why you don't remember? Have you ever driven home and not remembered how you got there? Again, automatic auto pilot. It happens when you do familiar tasks. That's why they should always have a backup systems that check for errors.
The technicians didn't check up on the patient. Plenty of the blame can go around to the technicians and administration. Plus it should not have been in Pyxis in the first place.
her employer is as guilty as she is. I'm a pharmacy technician, if we override the computer it has to be double checked and signed by another employee, any non-compliance would be flagged in a monthly audit.. seems that nobody was taking responsibility (including her)to protect the hospital, the employees or the patients. It's very scary that some institutions run with such a disregard for basic safety guidelines.. I don't understand how they legally maintain a license
@@Nan-59 yeah, employees don't make the rules, they just follow them and if nobody enforces them... Exhibit A I would run so fast from an employer that irresponsible.. rather than risk my own butt
Vanderbilt is a "teaching hospital." There's a wider berth for mistakes in those places than in hospitals that don't work with students on a daily basis.
As a retired registered nurse that witnessed many EGREGIOUS nursing errors, my experience was that the medical institution covered up these errors EVERY SINGLE TIME. It was despicable.
The thing that upsets me is that while the nurse is facing prosecution, Vanderbilt who is also responsible is essentially getting off scott-free. Our justice system needs better ways of punishing companies that behave badly.
I’ll accept the necessity of criminal prosecution of the medical community when criminal prosecution is just as eager and capable of convicting Vanderbilt as it is to prosecute Radonda Vaught. My fear is nurses will become scapegoats for hospital corporations.
@@calmbeforethestormo4136 Yeah they are. Giant corporation fails to protect their patients, and hides it for months? Blame the nurse! But only after there's publicity, and fingers start pointing at Vanderbilt.
The medical big wigs from the WHO and down to the family doctor are killing and injuring people by the 100s of 1000s and yet they are not being prosecuted.
I’m a nurse. A lot of drugs are similar in name. They teach you the five rights. Right patient, right drug, right dose, right route, right time. There are many factors that contributed to this error, but it does come down to actually reading the drug name and identifying the patient old school style.
exactly, where was her duty of care, the hospitals policies and procedures? she ignored the very basics, as Mark said, she deserves all she got. she is a disgrace to nursing, as is the hospital......that poor poor patient.....xxxx love to the family, In Australia she would have been ostracize rather than supported, and jailed. surely no professional person would support such negligent actions.
@@lorrainemoderate2816 i think what she did and what occurred is horrible and ridiculously irresponsible, but not criminal???, there is no intent to cause harm, the hospital did all it could to hide the facts from the authorities and when it finally comes out they throw her under the bus AND only then make changes to their system that helped cause the problem,
Those 5 R's are a sham, you do not have time looking at your 5 R's when you have 7 to 20 patients to medicate and 5 of them are crying, the other 5 patients are complaining of nausea and your phone keeps ringing and families and your CNAs keep asking simple and stupid questions over and over because they don't want to be responsible with their answers and want you the nurse to be the person responsible for all kinds of issues from toiletries to the toilet functioning to everything under that building.
She may saved the doctor's career too. My brother in law is doctor and I don't know how he does it. ONE decimal point off, misspelled medication names etc can kill someone even when a doctor is normally competent. Glad you're here today. My grandmother was a nurse, they really run hospitals.
So sick of big organizations covering up crimes. We teach and expect _kids_ to take responsibility for _their_ mistakes, accidental or purposeful, but adults go and do the opposite. You said precisely what I would have said about this situation. I wish I could give you a great big hug for understanding how I feel! Love you, Dr. G! 🤗
Unfortunately, this is how kids *used* to be raised. So many kids now have parents, teachers, and society at large making excuses for their poor behavior and performance and everybody gets a trophy just for showing up. I’m not surprised that adults don’t take responsibility for their behavior… their parents blamed the teachers for their kids failing!
As a nurse it's unfortunate the hospital didn't also face legal responsibility. I understand she made multiple mistakes however the hospital walked away Scott free. Edit: reaching a settlement with the family isn't justice
Hospital's cover up mistakes of all kinds because they will not hire enough nurses, nurses are the bottom of priority of their budget. Nurses need a strong union. They hire the newest RN and fire or "get rid of" longer employed nursed because it is cheaper. They don't care about patients, only the bottom line-their profit. Wonder if Vanderbilt still makes their RN as the unit housekeepers.
A settlement with a Gag Order. But the "for profit" hospital is totally innocent. They're about as innocent as their faulty epic system and pyxis. Bet her armband (that she didn't have on) would have been 1 of the many road blocks that could of prevented this. The nurse does carry some responsibility but she was also in a perfect storm that she shouldn't have been due to the failure of our medical system and society, people that have no clue what they're talking about are happily willing to stone her as they make her the scape goat. You know what I find the most disgusting? The fact that the leaders of this hospital, the owners, and all the other rich elites that have the slightest connection to this know what they did and they know what they're doing. They are going to keep shoveling out $$$ for the best PR, legal staff and media relations while they keep profiting and people keep dying. This is only the tip of the iceberg of what's been going on the past five years. I promise. Anyone not in the know, your ignorance IS bliss.
@@misstuxbrandi who knows if there is even a scanner down there. It should have been rescheduled like they originally were going to instead of a doc writing this order with no monitoring for last minute anxiety
The 3 checks: 1.) Check the medication with the patient's record 2.) After preparing the medication 3.) At the bedside after identifying the Pt using 2 identifiers The 6 rights to medication administration: 1.) Right Patient 2.) Right medication 3.) Right dose 4.) Right route 5.) Right time 6.) Right reason - being consistent using the 3 checks and 6 rights saves you from this nightmare
As a retired registered nurse, I totally agree with knowing the 5 rights! This was HAMMERED into us as students and on the state boards of testing to get your license. Pure neglect of not following standard protocols! This is sad all the way around!
Can there be a check where you tell the patient which medication you intend to use, and show them? I’m not a nurse so I don’t know how this would work out in the long run.
The patient should not have been left alone for thirty minutes whether she was given Versed, or any other medication of this nature. She could have been put on Oxygen and been put on a vent temporarily. All the other mistakes that were made were very much negligent in safe nursing administration of meds. I am an RN and have given Versed many times.
Vandy patient here, and i have to agree Vandy is partly to blame. I was also given the wrong drug at Vandy... AFTER my bracelet was scanned and everything. There were definite procedural problems. I often feel a bit guilty for not sueing them when it happened to me.. but i felt SO sorry for the nurse and when the hospital administration met with me i was in a vulnerable state, and they may have taken advantage a bit. I felt guilty suing, but now guilty for not
She was honest and upfront about the situation. The hospital swept it under the rug. If she's criminally culpable, then the others involved with the cover up should be prosecuted as well. We're constantly short staffed at the bedside and asked to do the impossible with limited resources. This is a complex issue that doesn't deserve one person being scapegoated like this. Sauce: I'm an RN, practicing for 6 years in the acute care setting.
Had this happen to a family member. Over dose of heparin. The nurse denied the mistake and I went ballistic and to the top of the food chain in that place. Already in a very compromised health situation, this would had been lethal for this person had I not been there. Don't be afraid to ask what it is and how much. It might jog someone's mind and avoid a mistake.
RN here. Please, never be afraid to ask what is being given/done to/for you or a loved one in any health care area. I want you to ask. “The doctor said I don’t have to take the red pill any longer” sends me right back to the order to double check again. That’s a win-win. You win because you get the right treatment. I win because I didn’t make a mistake and possibly harm you. Ask. Please.
Dr Grande, I cannot express my gratitude for your videos. I’m in hospital for a month. My chemo isn’t working, so I’m getting a bone marrow transplant. And I have to stay here for at least a month. That prevents me from getting sicker when I’m in an isolation room. So I’m not exposed to any germs. I was just crying so hard. Then I saw u just posted. I know I sound lame, but the humor u have also helps boost moral. Thank goodness that my medical service dog is staying here in my room with me. It’s helped me so much. And my daughter comes 3 times a day to take Jake outside to potty. She also brings me things I need. I feel so blessed to have Jake. And your humor also cheers me. I would have fallen off the deep end if not for Jake and UA-cam. This is the lowest time in my life. To add to things, my grand daughter was born with DIPG. She passed away 2 weeks ago. Then my daughter took her own life cuz she lost her daughter. Every small thing means so much to me. Right now I’ve lost all hope. I also feel that we shouldn’t ever ever waste time at all. Missing opportunities to spend time with loved ones, well it only leads to guilt. I would do anything to spend one more minute with my loved ones. So I’m working on not losing any opportunities to spend time with loved ones. Because that alone makes me feel so useless. That’s why I’m so grateful for videos and time I can spend with the family I have left. To I thank u so much. It’s a lonely life. And to add to this story, I worked as a RN and then BSN at Vanderbilt. I also knew this nurse. The best way is to say she is an EX nurse. She seriously was very strange. I’ll tell u more if anyone wants to know. It was so clear that she wasn’t right upstairs. I feel that she needed a strong antipsychotic and to be locked up. She felt she was above the law.
Her actions seemed murderous To me. Not a mistake. Even so , may she find mercy. As with us. May your hospital room be a veritable sanctuary for you.🙏🕊🙏🕊🙏 Healing Blessings!!!
Retired RN here. Every patient needs to have a family member with them at all times ( if at all possible) while hospitalized. Ask what medication is being given. Stay abreast of what medication the patient is to be given. My husband was recently hospitalized. His MD discontinued his blood thinner b/c he was bleeding internally. In comes his nurse about to give the blood thinner! Nurse argued with me that blood thinner had not been discontinued (while my husband was receiving a unit of blood due to the internal bleeding)! I told him (the nurse) to contact the doctor & to squirt that blood thinner down the sink. Nurse was indignant. This hospital made visitors leave at 8:00 PM. Before leaving, I found that nurse at the nursing station. I told him to make certain that the night nurse knew not to give the blood thinner. Be there, & advocate for your loved one! Any good nurse will welcome your concern & work with you to insure safe care for the patient.
My gosh, all I can think of is how much this poor elderly woman suffered! I watched the interview with this nurse, I didn't see any remorse, nothing. I'm glad you covered this one Dr. Grande 😊
I was an ICU nurse for most of my career and also did conscious sedation for a few years with the drug versed. I also administered paralytics and sedation while people were on the vent so I know any paralytic is brightly labeled with red labels and has multiple barriers to get into it. At the very least anytime you give an IV sedating drug you need to assess immediately for effect and come back within 10 - 15 minutes to reassess how the patient is doing. The effect of vecuronium is almost immediate and should have been noticed. Initially I was ambivalent about this when I caught the end of the trial and heard Ladonna speak to reporters but I hadn't known which drugs she mixed up. Now that I know more details I do think it's right but I don't know that eight years is appropriate. Med errors are most often caused by systemic failures but bad nurses can eff it up all on their own once in a while. The 2 neurosurgeons should also get a ding against their liscences for lying to the medical examiner. I hope JCAHO cited the hospital also.
I agree with you 8 years seems egregious and was an overcompensation by the State after the publicity associated with this case. It was truly a horrible way to die by being given a paralytic and I am not sure why it wasn't immediately noted when she became apneic and unresponsive. I am assuming she was going for an MRI, but she should have been observed for medication effect even if the nurse had thought she had been given versed there is still a risk of respiratory depression.
@@kitchenskills5427 And there were no techs in the imaging room for 30 minutes. They're the ones who found her. She died alone and probably terrified. This horrible death was not just caused by 1 nurse, but a system built to fail and then hide its mistakes.
I was going to say I don't remember Vanderbilt ever being regarded as a model hospital. I could not tell if Dr. Grande was being sarcastic or not in his intro.
I have argued with many nurses on this topic and they all seem to not be accountable for negligence . neither do cops. i argued them to resign if they could not administer the right drugs and double check before doing so.
That’s the thing, though, they won’t be, neither will any of the doctors who covered it up. This is the actual root of the issue. It doesn’t matter whether it’s engineering, nursing, whatever. Higher ups never get held accountable, it’s always the lower level employees who do, despite the fact that often the culture pervasive in their work environment is the catalyst for mistakes.
they get fined by CMS, and its usually a hefty fine. At our hospital a PREGNANT RN was allowed to hang an anti-cancer drug which is a no no. The hospital was fined $10,000.
I am a retired RN and I am appalled at how many times this nurse had an opportunity to rectify her original error and she did not! This is more than sloppy, it is criminal.
@@deborahmulkey1627 100 percent one can’t hope that technology is in placed to do all of the work. You still have to understand what your doing and know that there is a chance of mistakes.
Am I the only person that thinks perhaps the orientation process had something to do with it. Like when management tries to use an oriented as counted individual staff?! This case stinks. The error was so flagrantly avoidable. Or did this nurse have a drug problem the hospital wasn't dealing with. I feel like there is more to the story we haven't heard.
Why is the nurse the only one being held accountable? The hospital and its’ systems failed her and the patient. Redonda immediately reported what happened. Then the hospital covered it up. Who is acting criminally here?
What else could she do but report it? The woman was dead. There was no covering that up. But, you are right. The hospital is responsible as well. That was why they were sued and had to pay a settlement.
Yes, but hospitals are corporations. They are protected from the consequences of their actions. Besides Vandy is part of the historically spotless Tennessee government. And she is only a nurse, and individual ,where are your values?
As a practicing nurse i completely agree with the point of view presented in the video. Someone who is capable of making a series of such errors should not be a nurse, especially an ICU nurse where patients are particularly vulnerable.
I was a nurse for 35 years. Police and nurses should not be protected from criminal prosecution. The majority would never have made those mistakes. Having the power of life and death over others carries a heavy burden. If the consequences of your actions is more than you can shoulder then choose another way to make a buck!
I think Radonda needs to take responsibility for this, she said it herself. However, I disagree with your somewhat cynical take on the nursing profession that hospital mismanagement makes them feel at liberty to not pay attention. In my experience, nurses are much more worried they will take the fall for doctors and administrators' mistakes, rather than the other way round. For example, it is common for on call night shift doctors nearing the end of their hours to put off care so that days shift will have to deal with a given problem and they won't have to come in the middle of the night. If something happens as a consequence of this, it's more likely to be pinned on nurse complacency or miscommunication than physician irresponsibility. Things like that happen all the time. Most hospitals are understaffed and nurses are often expected to take unsafe patient loads, pick up mandatory overtime hours, and work in environments where cost cutting and mismanagement make it difficult to operate safely. This is far from the only hospital overseen by the type of corrupt individuals who tried to cover this whole thing up. Rather than complacency, the nurses I interact with go to sleep terrified that tomorrow is going to be the day when, overstretched and exhausted, they make a mistake such as this. Ultimately, Rodonda made a terrible mistake which she must live with, but it's plausible to say that her managers created an environment where mistakes were much more likely. It's a crappy situation, no doubt. It's also crappy that the corrupt admins who did illegal things (like ask nurses to override safety protocols in the medication cabinets and hide negligence from the police) seem to be facing no responsibility outside earning a bad reputation. Correct me if I'm wrong. Radonda needs to take responsibility, but more investigation is needed.
@Rocky I don't actually disagree - she made an inexcusable, idiotic mistake. The problem is that hospital administrations often make an environment where these sorts of errors are more likely. If nurses are doing (sometimes mandatory) overtime you could easily have someone coming on for their fourth or fifth 12 hour shift in a row, assigned more patients then they are supposed to who all need meds at certain time intervals or they will get more sick. Admins at this hospital apparently were illegally telling nurses to surpass some (to be fair, not all) of the safety checks on the drug storage machines essentially to save time and not have to hire more people. It's still ultimately her responsibility, I'm just saying there are plenty of people worth criticizing here.
We need a better system for sure. Yes. This nurse was grossly negligent. But these Pyxis dispensers have way too many warning so it becomes routine to bypass them. And the Pyxis system bypasses the check and balance of the pharmacist. Is that really appropriate for drugs like Vecuronium? Also, did the doctor order Versed electronically or was it a written or verbal order? Because when we have the nurse transcribe the order, get the medication out of the Pyxis and administer the medication, that’s just too many steps without any check and balance.
What a tragic and horrible death, and after listening to your video- what a inexcusable amount of mistakes that were made! I so agree with your comment "The RaDonda Vaught case is not a good example of a case that should have been ignored by prosecutors." Also really loved your final thoughts, Dr. Grande!
Of course she should have been charged. Like bad drivers that don't pay attention, are reckless etc, kill people on the roads. Imagine a delivery driver saying "but I didn't intentionally kill that pedestrian" - well, that's nice, but you shouldn't have ran the stop sign, while looking at your phone and driving on the wrong side of the road. It's not the same as if you're doing everything right and somebody jumps in front of your van and you run over them and kill them. It does matter if you intended to do something or not, but that doesn't mean you're now suddenly not responsible for your actions. You still messed up, you're still guilty of causing death to someone, who is innocent in that scenario. You have certain responsibility, you can't just say - "oh, stuff happens, nevermind. Now get off my back, otherwise other professional drivers will be afraid to drive their vehicles, because if they kill someone unintentionally, they might be prosecuted too".
I am an RN. The "system errors" that were in place before this nurse pushed the med are glaring. This is a sad day as med errors will now go underground and will never be resolved. So sad that it's, "Always blame the nurse."
I can’t get over how they had to ‘train ‘, their nurses to subvert the electronic double check system. I heard elsewhere that that’d been going on for a LONG time. There’s no way to tell what her work load was that shift, where else was she expected to be at the same time. She owned the mistake the hospital hid their culpability. That place should face severe penalties.
Here comes more documentation!! Nurses will bear the brunt of extra work. Check with 2 other nurses before giving? Have the unit manager check every med?
@@ean5469 My favorite ridiculous check is "check with the doctor or pharmacist" when there is one nurse, one CNA, 20 patients (many of which are fall risks), annoying family members everywhere, and the management threatens to write you up and/or fire you if your meds are not passed in time.
I was so hoping you would cover this!!❤️ I have worked with other nurses who have done this type of thing before!! I can understand once, but this was her second time doing this. She was fired from her previous job for the same exact thing and she had only been a nurse for two years. She’s not the only one a fault here either!
As a Registered Nurse who has been in this business since 1987, I can tell that you have no idea about conditions in hospitals nor the extreme pressure that nurses are under. I am not defending this nurse’s actions whatsoever. I would like to see a video from you showing the dangerous understaffing of hospitals all over this country. Apparently, the general public has been kept painfully unaware of the national nurse shortage and the dangers associated with the shortage.
It is by design this is happening. Hospitals are big business here and they decide on what is reported. I am positive many politicians and news companies have agreements with these places.
Where is the psychiatric analysis of health care workers being forced to work in understaffed hospitals routinely? Air traffic controlers and preschool teachers have govt mandated stafty ratios. What about the patients? Safe staffing matters for patient safety.
@@jenniferr4364 corporations run private hospitals and they will squeeze the most work out of healthcare workers without worrying about consequences. It is all about the profits and pleasing their stockholders.
Dr Grande, I love this analysis. I would compare a nurse who kills someone with a medication error, and no follow up, to a peace officer/police officer who accidentally shoots someone. Yes accidents happen, but there are accidents, and ACCIDENTS, which could basically be prevented, with a slow down and think moment. When you choose a career, making yourself responsible for other people's lives, you are then responsible. Thank you again for these great analyses. Love from (the still snowy) Canada 🇨🇦
One further comment. Vanderbilt covering it up most be a common theme. Everywhere our local serial killer, Elizabeth Wettlaufer, worked, they covered up her bad behaviour. She was allowed to move from place to place, abuse drugs at work and be caught, make many medication errors which she was fired for, kill 8 people with insulin like it was nothing, injected how many others, and would never have been caught until she voluntarily confessed. She never lost her nursing license for all her recorded bad behaviour; although it was suspended once.
As a retired ICU RN for 40 years - I can tell you that the paralytic administered to her rendered her helpless to move anything, including her diaphragm, and she had full consciousness through most of the time it took her to smother. Question - video says she was a "licensed " nurse. Is this an LPN or an RN? There is a big difference in responsibilities. Absolutely NO LPN should be allowed to give Versed.
I’m a nurse and I agree with the charges. There were too many safe guards in place that she completely neglected and then didn’t even monitor her patient afterwards is unacceptable as a nurse. Her main job is to monitor change and she failed on everything in this situation.
As a registered nurse, I can tell you that you are taught in nursing school from day one to READ the medication label SEVERAL TIMES before administering any drug. You also have to monitor the patient. She should lose her license at the very least. The hospital needs to be punished for their part. With that said, nurses are often given dangerous patient loads that will cause more errors and neglect. I have no idea if that was also a factor, but this nurse was acting in a dangerous manner.
You are the best commentator on line. Your voice is so expressive and measured, very easy on the nerves no matter how horrible the case. You also have a delightful dry sense of humor. Please keep on commenting on the cases that no one else can make sense of. I am a fan!
Taking the erroneous medication out of a "Documed" type of dispenser is one thing. Initially I had fortified the nurse, but as the facts kept emerging, it got worse. One of the cardinal rules of administering any medication as a nurse is the "Five Rights" or the "5 R's"l 1. Right Drug 2. Right Dose 3. Right Time 4. Right Route of administering 5. Right Patient She mentally conceived she was giving Versed, she should've checked those rights twice, let alone giving Vercuronium. It's not rocket science that you should follow these guidelines. Every instinct in her should have ceased her. However, the cover-up Vanderbilt orchestrated and executed, is nothing short of horrible. From the CEO down, they all should be held accountable for being an appendage. The family being able to be bought off for their muteness is revolting and Vanderbilt is a Despicable hospital.
@@jessetaylor7951 Fortified means to strengthen, encourage, secure. The hospital not reporting the incident gave that nurse the strength to move on without consequences.
Finally, I hear someone speak some sense! I've seen so many nurses on social media stick up for the woman and it terrifies me! One mistake fine I can understand, but she multiple serious errors. My father fell at home and was taken to the hospital. Someone messed up his medication at the hospital. He had to be resuscitated and was in the ICU on an intubation ventilator for a few months. We didn't know why he was in the ICU for a fall until he was released from the hospital and the family doctor told us what had happened (apparently it's the procedure?). It's been about 5 years now and he is still in a wheelchair because he never was able to walk again. Dangerous people shouldn't be around vulnerable people.
Yeah, Vaught lost me when she didn't scan the medication and patient's bracelet barcode. It's mandatory to use the bedside medication verification specifically to avoid situations just like this.
Totally agree. I’m a clinical lab tech. I could understand one or even two of the errors she made but by not even attempting to verify the patient’s identity with a simple barcode scan, she lost me. Like I’m having a hard time not thinking there’s more going on here.
Okay - I based my comment on the information presented here and Dr Grande said at 8:35 that Vaught did not scan the medication and patient's wristband (implying that she could have).
That nurse just made too many mistakes. Agreed, at some point the negligence just becomes so gross/reckless that it does rise to the level of a criminal offense. Especially if it causes the painful death of a vulnerable, elderly patient. The hospital also should have had better oversight and safeguards in place.
Thank you for speaking sense. Every nurse is saying this will set a precedent, but don’t talk about how negligent the nurse was. You can’t blame stress or a place being to busy for a death of an innocent person
yeah, that list of things she had to ignore to make this mistake was pretty damning. ignoring that many warnings and procedures, but having enough presence of mind to perform an override? how can that happen?? she's dangerous
I'm wracking my brain about this. I'm wondering, and there is still definitely fault on the part of Rodonda, if she and her orientee were used as separate staff and thus she was counted and they were separated. I'm wondering if the orientee made the error. Hospitals routinely try to take nurses prematurely off orientation. The drug that was supposed to given is never reconstituted. Just the fact that the med needed to be mixed would give any nurse pause, enough to call pharmacy or at the very least another nurse. I realized seeing pictures on another video something I had forgotten, versed is always in a brown bottle. It must be light sensitive. There are problems with the med dispensing systems, but a nurse who works in ICU would know to monitor a pt and not leave the pt. The pt should have been on a monitor in the machine! I had heard the nurse was called away to the ER. The hospital attempted to hide this event. Perhaps the idea is to trial this nurse to open up testimony to further prosecute the hospital? I don't even know if that's a thing.
This case comes down to a nurse misreading the label, and the hsopital not having a scanner that worked. They claimed they fixed it but it was not fixed. Now I'm not defending the mistake, you can't throw nurses and doctors in jail when they make every mistake, all nurses and doctors would quit because it's just not possible to never make a mistake in your job. Lets remember your asking for people to be absolutely perfect all the time. Lets try to remember she had never previously had a med error and she reported herself.
I needed to read your response. Glad I did. I was texting my outrage to the analysis and saw the word in your post that calmed me down. The word is "gross", gross negligence. I have had and have heard of close calls but never to this extent. The governing bodies need to ask about the elephant in the room. Why did she show such gross negligence? There are a lot of "Whys". We all need to ask why did this happen and how can this be prevented in the future. Will nurses become lees forthright in reporting incidents? Why? or Why not? So far a response to the whys only get crickets. It is better to be humble and realize that you have the wrong drug instead of feigning that you know what about a drug. The preceptor seems to be the reason for pushing on. Nothing else makes sense. If that is the case then criminal charge is a no-brainer, but how do you prove that.
My dad is a nursing instructor with a master in nursing. He was an EMT for 30 years and an ER nurse as well. I asked him what he thought of this case, he said you ALWAYS, ALWAYS double check, triple check and quadruple check the medication before administering it, no if ands or buts about it. When people's lives are in your hands you have to be hyper vigilant. When and if, heaven forbid an accident happens you are always upfront and honest about your mistake and take responsibility.
As an anesthetist it disturbs me that anyone without anesthesia training would even have access to Vec or any other paralytic for that matter. It should NEVER happen for any reason. They aren’t taught the uses and dangers of these drugs and therefore shouldn’t be able to touch them.
I'm not in the medical field, but I heard the drug she used is usually locked up and the packaging has extra color so it can stand out that it's stronger than most. She sounds like a sloppy nurse. You listed a lot of other ways she was negligent. If you aren't capable of paying attention to details, please stay out of the medical field. I feel for the victim and her family. It was a senseless death 😢
The drug she pulled should NEVER have even been on the floor she was on- it’s a paralytic used to intubate people and only used by anesthesiologist who pull their own meds separately. The medication dispenser where she got the med from was broken and the scanner that verifies patient ID and proper med was broken as well. The physician also made it a verbal order- meaning it wasn’t in the system and he refused to write an actual medical order. Nurses are instructed to follow a verbal order immediately by a doctor bc it usually indicates an emergency- the doctor was the lazy one
@@whalefuhk I also heard that the machine where it was dispensed hadn't been working right. Nurses now need to protect themselves and have it all written which is impossible to do during a true emergency, like someone going into anaphylactic shock or someone having a heart attack or stroke!
No disrespect, but if you work in the medical field you’d know how easy it would be to make this mistake with all the safeguards removed. I have to work with more than one person talking to me at a time and their family on hold, angry because I haven’t picked up the phone. There’s only one of us usually doing the job of 4-5 people.
@@facemuscles9 I appreciate this comment. That's why I wanted to start my comment basically saying the point of view of "someone from the outside looking in". So you're saying it was pretty inevitable for this to happen and would've happened to ANY nurse at that hospital?
You’re the only “true crime” guy I can really watch! I enjoy learning about people and why they do the things they do, and you’re able to provide the facts without making things extra “spooky”.
❤❤She testified 2 hours to TBI without an attorney . The DAused this 2 hr testimony in court against her. Her attorney Peter Strianse was an attorney to a high profile case in 2014 . Vanderbilt football players involved in a gang rape of Vanderbilt coed . Peter Strianse represented Corey Batey in appeal. This was Radondas attorney as well
I just retired as an RN of 45 years. By the Grace of God I never made a mistake like this but,all I can think is: That could of been me. Anyone being so pious is just wrong. There were so many holes in this system that, unfortunately, it made for a perfect storm. Nurses need to unite, not divide. The hospital is the one that should be on trial here. It failed to report the error which opens up for chances of possible increased errors. An out of court settlement with a gag order was made. Now, for some odd reason, it’s brought out again into open and I feel it’s the hospital trying to cover up. Administration knows of RN’s being understaffed yet do nothing about it and know we won’t walk out on patients or an assignment . I was taught NOT to let patients know we are understaffed. We were made martyrs.Why did the hospital not have patient/med scanners? It’s about doing the most with bare minimum. The hospitals will work the medical staff to the brink of collapsing while administration is on holiday in Figi.
I’m an ICU Nurse, 24 years. This case: disturbing on a lot of levels. Her mistake was bizarre when you compare the two medications. Most people in my business call Versed midazolam. We don’t use brand names. Typically a Pyxis or Omnicell won’t deliver Versed. If you keep pushing the letters VE, the Pyxis says ok, you keep asking for Ve, I will give you VEC. In addition, if all these hospitals keep trying to do more with less, this is what you get. COVID just put the shortages under the microscope. I will say, this mistake…. Unacceptable.
Excellent analysis. As a non-medical person, I've worked in the medical community for a few years. Cover-Up , is a big thing. It's disgusting and criminal.
You are right, It's a super big thing. I have a BSN and I get continuing education course material (and internally they warn/teach that 250,000 patients will experience an adverse event ANNUALLY and over 100,000 will die from care received ANNUALLY) this is something they internally acknowledge is a major problem. That is why so many other nurses went on TV saying she shouldn't be punished harshly.... because they fear similar repercussions for something they know is SUPER PREVALENT and statistically have all done themselves. I had to leave the medical field because my pointing out all their errors and trying to fix things creates a 'hostile work environment' according to HR
@@SoManyRandomRamblings Thank you, Random Ramblings for your response. In the early 70s, I was in a nursing program. After two semesters I was asked to leave the program. Because I asked too many questions.
Dr. Grande, I'm a RN and simply put- I agree with your opinion and analysis on this case. I can not EVEN believe how many safety barriers she broke through~ how many errors she made which ultimately lead to killing this poor woman! I just don't get it, not at all. I'm so glad she's not a nurse anymore and the jury got it right.
Oh what a great request, Rejane! This is a case that represents a lot of what I am angry about with unethical conduct in big organizations. Congrats on him doing it; it's a special moment when you see your request in video form in the notifications! 🤩
@@annal7364 Thanks Anna! Yes, this case has the medical community up and arms. Vanderbilt should have owned the responsibility for covering up this, it’s just outrageous.😣
As an RN in ICU for almost 30 years this whole thing was very preventable if the safegaurds are used! A nurse has to stick to the basics of med admin,=Some take shortcuts to get the job done in todays hospitals with short staffing and more demands on the nurse! Nurses need to be tough enough to refuse to work when safegaurds are bypassed==I have quit jobs where I believed it was not safe for me or my patients== safty systems do not work when Hospitals save money with short staffing!!
Unless you work in a hospital you have no idea what it’s like. That is what is so frustrating. We can’t even began to tell you how it is. I can guarantee that any nurse who has ever treated you or a family member has made a medication error. Most are so small it doesn’t get reported because it causes no harm.
@@Wazupiseeyou because private hospitals don’t care about competent nurses. They just want there stock numbers to go up and please their stockholders. They just want warm bodies in there. When they make a mistake they will throw them under the bus even though many factors go into these mistakes.
Not only did Charlene die~ but she suffered terribly!! This nurse was not emphatic to her patient. She was totally 💯 irresponsible and obviously nursing should not be her career. Glad the situation came to light. That patient was ready to go home before she suffered and died🤮😡😭
I admire how you articulate the facts and explain the terms in an organized concise manner in simple terms and of course with that bit of sarcasm to lighten things up. I also appreciate how you share your thought analysis at the end to provide moral perspective. Your platform is a great service to many in understanding “the system” and human nature. You’re right this was a very sad case of lacking principles and accountability for the nurse and organization
Vanderbilt hospital shares the responsibility of what happened to this patient. First they were having problems with the mechanism, second why was vecuronium put in with Versed? Vecuronium is clearly an anesthetic agent. No anesthetic agent should be put in a cabinet with Versed especially right next to Versed.
I agree! Absolutely! That medication should've never been available. And THAT's on the hospital. Nurses are very overworked. The good doctor here says nothing about that.
@@Nan-59 there are very few places that members of the general public can enter, kick punch and spit on you, then leave with no consequences. Working in hospitals today is a nightmare. If I had a financial exit strategy I’d be done with this line of work.
I have some thoughts on this. First I would say that what is good for the Goose is good for the Gander. I have personally seen things that Doctors have done that ruined a patient's life but lawyers say that it is impossible to sue the bar is too high. Another thing is that not all organizations cover this type of thing up but they are Very willing to throw the nurse under the bus when there are many flaws in the way they operate which led to the mistakes. Number one is insufficient staffing compared to the patient load.
Thank you for this video. I hope it reaches at least a fraction of the nursing community who have embraced this nurse and defended her gross negligence . I am, of course, deeply disturbed at this nurse's obvious gross incompetence and being portrayed subsequently as a " victim" herself-- a portrayal which she seemingly accepted. I am deeply concerned with her apparent lack of genuine acceptance of her responsibility in the suffering and death of this patient. In my opinion, the prosecution and conviction of this now- ex nurse was just, fair, and necessary. The attitude of a substantial number of nurses regarding this case- as demonstrated via social media-- is disheartening to me. Some demonstrate such a low level of basic reasoning in excusing her actions as " an honest mistake" ( whatever that is), that one should wonder how they themselves are functioning. They cannot see that-- obviously-- " the healthcare system" indeed, cannot police itself. Then there is the morality of the collective nursing community. The arguments made in support of this nurse include this perhaps pathological belief that she has been made a scapegoat of a massive corporate healthcare system. While Vanderbilt Hospital did indeed have some obvious flaws and willfully engaged in a scheme of deception after- the-fact, no hospital administrator took a paralytic out of an automatic medication dispensing machine, ignored the warning, reconstituted a drug (that any neurological ICU nurse would know did not require reconstitution) etc. No administrator injected this medication. No administrator failed to observe Mrs. Murphy for the effect of what was believed to be a sedative. Only this nurse could be held accountable and responsible for these actions. Further, many nurses claim that this case will cause nurses to not report their errors. So, what these nurses are stating is that nurses will lie about their medication errors? ( Actually, many already do). That belief demonstrates a rationalization for and acceptance of a reduced standard of care in an occupation that is already compromised by fast-tracked nursing education and the recent depiction of nurses as "heroes"--- which many seem to have taken to heart. Good nurses who care about the standards of care-- those whom you want at the bedside-- will see the benefits of the outcome of this case. Those who histrionically claim it will cause a mass exodus from the occupation-- perhaps should consider leaving as well. In my own careers as an ICU and ER nurse, an ARNP, a nursing instructor, an expert witness-- I have learned that the closing of ranks by nurses to protect one of their colleagues is a sign of a flawed collective conscience, if you will. I can only hope that the relatively small number of nurses who justly and accurately comprehend the magnitude of this nurse's negligence will ultimately influence their less aware colleagues.
The worst part is the patient was given the diazepam because she was claustrophobic and was scared of being in the CT machine. I feel like that might have been her biggest fear, slowly suffocating to death in a confined space . Horrible. Just horrible. Im glad justice was served .
If she had administered a non lethal drug by mistake--no harm no foul. Same mistake but no repercussions. . What is to be gained by putting her in prison--she no longer has a nursing license so she is no danger to the public.. This is a bad precedent--it's the rare doctor, paramedic, EMT or nurse that on a busy, stressful shift has not made a mistake. Do they all need to purchase individual malpractice insurance and drive the cost of health care even higher. I posit that if the hospital and nursing board had done their job-i.e immediate investigation and disciplinary action, including revoking her license, the person who likely felt like RaDonda got away with this mistake and turned her in, would have felt like something had been done and wouldn't have taken that step. Happens all the time.
Doctors are given far more professional leverage in “negligence” situations. They get a pay to play via insurance payouts when they fuck up. This is a labor inequality issue.
💯 Do you know how many patients don't get the care they need because insurance doesn't cover it and doctors are forced to find ways around that. In most cases that leads to the patient not getting the proper care that they needed. I don't know why insurance gets to be the deciding factor on what treatment you receive. It's all about money. It's going to take the top guy to the bottom guy to fix this.
The worst part about dealing with doctors is they are usually too arrogant to admit they made a mistake... Or God forbid a less educated person correct them, even though that person may have more work experience in that particular area. I work in the medical field, trying to give doctors advice or correct them is often a losing battle
When I first heard of this case I did not realize how many of the safety factors she ignored! The truth is nurses override the medication dispenser all the time, especially in critical care areas where you need to have access to drugs the pharmacy has not yet released to the patient profile. I could see how in a hurry she would pull the wrong medication but there are so many red flags past that point that she ignored! The fact that she had to reconstitute that drug is a biggie not to mention not scanning the patient's arm band! There have been times when I have pulled the wrong IV solution or medication and the armband saved me! At the very least that patient should've been on a portable monitor when in the CT scanner! What a terrifying way to die! You are right… Hospitals do hide mistakes! I think criminal prosecution is a good thing!
Sooo many nurses are supporting her blindly simply because she is a nurse and so are they. I started doing research on this case, rather than watching Tik Tok videos on the case. Man, she ignored so many red flags. She admitted she was not busy, that this was not urgent. So why did she hurry to give the med? Call pharmacy, have the med verified. I am not perfect. I have had close calls too in my career, but this was extreme. She was an an experienced critical care nurse. So avoidable. She ruined her life. I honestly feel bad for her, but ghis pt died in a horrific way. One lawyer described her death as being burned alive would be the worst way to die, while the second worse way to die is the way this poor woman died.
@@user-pl1hz8pu1p I know nurses who think she should have lost her license but also think that a manslaughter charge was inappropriate for a medical error. This really is a pivotal case because we have previously seen such cases handled with loss of licensure plus a malpractice settlement. I do agree with this decision but I’m just clarifying because I’ve heard from lots of my nurse friends.
@@beagledog2001 I saw another video that claimed that there isn’t an armband scanner available in Radiology at that hospital. It was a doc who goes by ZDogg.
This is the best explanation of this case that I have heard. I was surprised when I watched the trial that the victim’s DIL said the family didn’t want the ex-nurse prosecuted. Truthfully I wouldn’t have been that forgiving. I’d want the public (possible future patients) to be aware of what happened.
I agree with your analysis. Humans make mistakes, but it does matter when those mistakes are especially wanton. The solution (if there is one) is to use technology to help prevent or alert to such mistakes -- and to automatically document everything that HAS actually happened. Realistically, that will the "best" that we can do.
I have watched med errors happen at a hospital. None that were fatal but , it does happen. When it did, the nurse reported it: the hospital l had a meeting and created new measures to check the medications between the doctors, pharmacy and nursing : and then trained all the nurses on this potential error so that it won’t happen again. That is how mistakes should be managed: review the issue, find out what caused it, prevent it from happening again. Not ignore it. Not brush it under the rug. Because ALL of us will be in a hospital bed someday and we have to know we are safe.
I am a nurse and she violated a basic basic nursing 101 medication pass rule of verifying a medication 5 times before giving it. Being in a hurry or stressed out is no excuse because she is the last safety check in the process even if hospital or pharmacy shouldn’t have it in the Pyxis. She did Not do her job well. Having a student with her should have slowed her down to teach the student to check it as well. They should have talked about the medication as a teaching moment so I don’t have a lot of sympathy for her.
I wondered about this too. It’s an odd name. I also wondered about the way they treated a 75yo woman. Geriatricians have noted that doctors often discount the value of older patients. Louise Aronson’s book Elderhood recounts a doctor who said he’d have responded sooner to a call if he’d realized the patient was younger. An article in J of Gerontology suggested that nurses are the most ageist of health professionals.
The nurse did not cover up her actions at any point. She admitted her mistake to charge nurse immediately, as code blue was called overhead. If she did not say anything, no one would ever know, paralytics dissipate quickly, there would be no reason to suspect anything. Literally, the ONLY REASON this is know is because she admitted her mistake immediately. As for the monitoring the patient, she was told to leave by the MRI personnel, she was told that they would monitor the patient. Also, the only way to truly monitor patient in MRI is to have patient hooked up to MRI compatible equipment that can stay inside the room. If patient did not arrive on transport monitor (as ICU patients are always travel with ICU RN & monitor + the drips), it is not a routine practice to place patient on the monitor, even if meds are given. The hospital cover it up, even when nurse told the truth and admitted her mistake immediately. Mistaking one med for the other, holly sh!t, they are nothing alike, it does not even say Versed on the bottle, it midazolam. The hospital does not even get a slap on the wrist for this cover up! She made a mistake, admitted to making mistake, paid for it with her job & license, and now prison time, but ever happened to the hospital? Maybe, just maybe, someone should look into how they operate, maybe find a few doctors who made a fatal mistake, and absolutely nothing happened as a consequence.
She didn't admit it right away, though. And she didn't just make a mistake (or even two) -- she made a series of surprisingly negligent decisions. The machine warned her like 8 times and the medicine label had a big "paralytic medication" warning on it. She then left the patient alone to die an excruciating death. The hospital behaved horribly, too, and I think those administrators and doctors who covered this up should also go to jail. The whole thing's a mess, but the nurse earned the jail time and license revocation. No way would you want her taking care of your family members, I'm sure.
@@chocolatethunder192 yes, she made multiple mistakes, as an ICU RN, I am very concerned over giving "whatever" & leaving, even she was told to leave by MRI staff. She was not assigned to the this patient, she was "floating" & had an orient with her. Typically, very few things can safely go inside MRI bay room, med scanner is not one of them, it will get pulled into the MRI & the whole things will have to be shut down for very long time... The only time to scan patient's bracelet is prior to the start of the procedure, in the hall. Regardless, this facility did not even had the scanners there in MRI. But big fat letters on the cap & label should have been a warning. I am not justifying her actions, but I thing she should not be THE ONLY ONE paying for the system failure, lack of check points in the process, not to mentions the whole hospital cover up, including multiple medical professionals, doctors & administrators. As it stands right now, she is being made an example & a scape goat.
It only takes a second or two to double-check that you have the correct medication. She was grossly negligent in what she did. My mom was a head nurse for twenty years, so I am familiar with proper procedures. She should have read the vial out loud to herself, and again when telling the patient what its name is and what it's for.
As a nurse and as many of the nurses in the comments have said, the precedent being set here is dangerous. I fully agree she should’ve lost her license and was negligent. Nurses are human-imperfect people working in a very imperfect system. The responsibility cannot lie solely with the nurse when there were clearly multiple system failures that contributed to the mistake. Mistakes are inevitable and it’s true that the stakes in a healthcare environment are much higher. That’s why we have channels for reporting errors that are supposed to lead to a proper investigation, identification of the causes, and putting new systems in place to prevent them. Here there’s a nurse who reported herself and tried to go through those channels. Where is the responsibility of the hospital system being addressed? How did this get swept under the rug? Those are the questions of consequence here. Now more than ever, hospitals are pushing nurses to work in unsafe conditions with unsafe staffing ratios yet we’re still held to the same unrealistic standard that mistakes are not acceptable.
This is an excellent example of why you DOUBLE CHECK every drug you are administering. DO NOT rely on vial cap color, on abbreviations, on the right thing being stocked in the correct pocket of the pyxis or the omnicell, etc.. ALWAYS CHECK. Since the nurses were required to override the system check, that means they should have been on high alert and even more vigilant than usual. There is always human error in these systems but READING THE VIAL to identify and confirm the drug and concentration takes ONE TO TWO SECONDS MAX and is bare minimum for safety. ugh this is just so so bad I feel horrible for the patient.
Your comment is textbook sanctimonious. Disregarding the realities of a tired mind that doesn’t think any longer to do all those basic required checks.
What a horribly tragic and needless death of a particularly vulnerable patient! Disgusting that some think the medical community should be immune from criminal investigations and charges. Disgraceful that the hospital tried to cover up this criminally negligent death!
Professional organizations always want to police themselves. And when they mess up. In their mind the ultimate punishment that could ever be handed down is the loss of a license. When you're in the business of holding other people lives in your hand. The ultimate punishment should be criminal prosecution. How many times have you heard police departments repeat the narrative. Just need more or better training? Every incompetent action is blamed on training or procedure. Not personal responsibility.
I agree. If i mess up at my job, i will get prosecuted and rightfully so. If you're handling peoples lifes, the worst thing that could happen is death, not a career change.
They don't do it that way, because over 100,000 patients are killed EVERY YEAR due to medical mistakes, they wouldn't have any staff left if they held people properly accountable.
I am a registered nurse, and while it's inevitable to make some medication errors during a career, this particular set of events is horrifying. most people outside of the hospital don't know that the number of medication errors nurses CATCH on doctors' orders is astonishing, and no one is talking about this. we find an error, call the doctor, and give him/her the opportunity to self correct. the nursing board should have taken away her license from the start, but criminal charges?? if we go down this rabbit hole, nurses may not self report medication errors, which makes everyone much less safe.
There’s a lot of people who haven’t worked in a hospital in here and it shows. There are some major systemic problems that contributed to this error that are completely being ignored in favor for blaming one person. Why was this med in the same machine that served the PET? It’s not exactly a med that is administered often there and it should not have even been there. Why was there no second nurse override? Most hospitals have a two nurse override and no permissions for a nurse to blind open a full drawer. Why isn’t the hospital system being held responsible for their part of the coverup, which the nurse didn’t actually participate in. Why wasn’t the patient monitored? Was it a drop off or was a tech supposed to have been there as well, what were the protocols and how were they not followed. Did she not scan because she chose not to or because she wasn’t able to? (I am actually not sure about this answer.) Yes. She made a med error. She made the steps that created the situation. However, that’s ignoring the fact that she should not have been able to make many of those mistakes.
I have been an RN for 40 years. Mistakes are going to be made in a hospital setting every day. Some are small, some are extreme. If anyone in healthcare believes they are impervious to making a mistake, they are dangerous. Nurses and doctors are HUMANS who want to help others in a setting that is always stressful, always changing, always complicated, always understaffed, always physically and mentally demanding. Ms Vaught had no intention of inflicting harm. To prosecute her as criminal is horrendously unfair. If placing blame and responsibility on the bottom of the medical community food chain is what society chooses, I would advise no one to go into nursing. So who will take care of you when you need a nurse?
I'm in the nursing field and I was just made aware of this case a couple of weeks ago... but, yeah, trading versed for vecuronium is a sentinel event: one which results in grievous harm or death due to neglect of safety protocols, it's sobering, but we exercise the 5 rights of med administration for a reason (right patient, right medication, right dose, right route, right time)... adhering to these would've prevented this...
People are saying this is a balanced analysis. It is not. Dr. Grande fails to mention the numerous systemic errors: the nurses being instructed to override the system; RaDonda being told it was okay to leave the patient; the fact that this was not Radonda's patient; the fact that a scanner was not available, to name a few. However, I still feel she was criminally negligent for NEVER checking the vial to make sure she was giving the right medication. Even so, I wanted to point out that this is NOT a balanced analysis. I also agree with others that the hospital needs to be held responsible at the very least for trying to cover up the incident.
It's unfortunate but doctors/hospitals often bury their mistakes. We put healthcare professionals on such a high pedestal that we often have blinders on and don't do our due diligence researching doctors, surgeons, hospitals...If this patient had no family this likely would have been brushed under the rug. I do have respect for healthcare workers and doctors and realize they can often save lives and help improve our quality of life. However they are human, make mistakes, can be impacted by stress and some are more skilled than others.
I watched a lot of this trial. The nursing expert was fabulous. She had almost 5-0 years experience. She list 15-20 separate acts that had to occur for the mistake to happen. As a recent surgical patient, listening to the circumstances of the case were terrifying.
There's a saying that my dad used to use when speaking of doctors: he would say "not all doctors were "A" students in med school". He was, of course, pointing out the incompetence of some in that profession. I believe it applies here also.
Yeah. It seems to me she was generally a terrible nurse. I’ve even wondered if she’s just not very bright, or if she were on drugs, or if she’s ADD and can’t focus … nothing, however, nothing excuses her behavior. Unpardonable and reckless.
True. When one goes to see a Doctor (even a Nurse Practitioner) that Patient doesn't know if that Doctor or NP graduated at the top of their Class or at the bottom. They are like the Shadetree Mechanics of old - there are some good ones, some bad ones and the rest are mediocre.........
I am a nurse and I am kind of confused why a paralyzing agent would be in a Pyxis machine in the first place. This type of med is used for intubation and regular staff nurses don’t do that procedure. If the hospital would have kept these meds locked away and only certain staff would have access to it, then this never would have happened. The hospital and medical examiner should also be prosecuted because they both covered up the error which is negligence on their part. Since the hospital has all the money and they never seem to punish doctors when they make mistakes, the nurse ends up taking the fall for the entire incident. And I heard that she was helping out another nurse when this error happened, maybe if hospitals and nursing homes had safe nurse to patient ratios, med errors would be reduced and lives would be saved. Just my thoughts.
This is a system error! He showed the lid too on a tiny valve like anyone could see that!!! This nurse was training another nurse at the time too! There was too much risk in this case! The system failed her!
@@PurposelyObtuse when I was a nurse working inpatient psych there was almost a med error with clonidine where the doctor misplaced the decimal point and the nurse almost gave a patient 2 mg instead of 0.2 mg. Another nurse caught the error but the original nurse almost gave it even with a big red alert on the Pyxis drawer. I no longer work with patients because hospitals risk nurses licenses and patients’ lives everyday with overworking nurses and having unsafe nurse to patient ratios. I would rather sit behind a desk and not risk the license I worked very hard for. People that judge nurses for making mistakes never worked a 12 hour shift with a high work load. When people are overworked and extremely tired, they make mistakes. Hospitals know this but they fail to put things in place to make sure things like this don’t happen. And they end up throwing the nurse under the bus to take the fall. It is truly a sad situation. And they wonder why nurses are leaving the bedside.
Then go after the politicians who take funding from big healthcare corporations to keep these staffing levels completely inadequate.
They put nurses in a position to fail.
They make sure nurses take all the risks so they can avoid any legal ramifications (if anything goes wrong they blame the nurses).
@@btetschner you state the truth.
This is a lesson to know and practice our five rights every time! Right patient right drug right dose right route right time.
We use the 7 r's additionally right documentation, right response
My husband (a former USAF medic and a one time nursing student) and our friend (a former USAF medic and current nurse) were literally talking about the 5Rs last night. They both had them drilled into their heads in the first weeks of nursing. My husband, even though not having completed nursing school and having learned it over a decade ago, still has it memorized.
This case hits a bit close to home for him as if he hadn't questioned what antibiotic a nurse was about to give me while I was asleep post delivery, I would be dead. The nurse never checked the bright red allergy band on my wrist and almost gave me a drug that would have sent me into anaphylaxis. Too many people skip safety in favor of speed.
Talk about a guardian angel!
This is a lesson that all people can make mistakes and criminal prosecution will make healthcare less safe. Why tell the truth if you can go to prison? Just Culture.
@@janiesmys461 this was beyond a mistake. This was her criminally ignoring her training. This was not just a lack of professionalism, this was negligence on a lethal scale. Giving an incorrect dose is a mistake. Giving a medication that comes in a completely different form, has warning labels, and failing to do the most basic steps of your training goes beyond an error. If a medical professional is so worried that they do their job so badly they could be criminally liable than they shouldn't be in the medical field.
I'm a nurse. This case disturbs me, makes me think. Cases like this can make me consider my own practice in a critical fashion. The idea of "missing something" has always given me pause, and I'm sure it makes other healthcare workers think twice and thrice. Maybe that's the only good part of cases like this - if you let them, they can make health care workers examine themselves, and perhaps avoid future mistakes.
When I heard of this case, my first thought was, didn't Radonda monitor the patient's reaction to the drug after she gave it? Couldn't she tell the patient's vital signs indicated increasing distress? Versed's not something you administer, then walk away for half an hour. You monitor the patient, for God's sake. Sedated people are extremely vulnerable. Hard to say how and why the patient went unmonitored. Bad practice? Distraction? Overwork? Complacency? I suspect there's more to the story.
Vanderbilt Hospital's hiding what happened doesn't surprise me one bit. It's partly an outcome of the idea that a hospital should be run on a "business model" (@@) rather than as a health care center. There's also this myth that healthcare can "take care of its own" including its own bad actors. In my opinion, it cannot police itself, at least not entirely.
I'm sad for the patient and for her family. The patient's death must have been awful.
I'm conflicted about Radonda. Usually when big medical mistakes happen, they don't happen in a vacuum. They are an outgrowth of a wilderness of error, combined perhaps with increased-on-chronic personal stress.
The stakes are high in healthcare. It's extremely important for healthcare workers to be in environments that monitor for distracted, overwhelmed workers and that honestly encourage telling the truth about mistakes.
Radonda was floating that day, taking a patient to MRI, had an orientee with her. She was like a transport nurse that day. She gave the Vecoronium and left the patient in MRI where there was a delay getting the patient in the scanner. I agree this was an ICU patient, we always had to monitor ours during transfers. System errors caused this death from the Pixis override to leaving a sedated patient. Their policies were to blame.
Your comments are excellent!
Thank you so much for your insight and professional experience and explanation. Anytime I got Versed was prior to a surgical procedure and was monitored carefully. My heart goes out to this poor woman's family. My niece went to med school at Vanderbilt, and has always been thought of as top notch.
Hospitals should probably conduct literacy exams for their new staff. Just an idea, wouldn't harm anyone.
@@purplgrits7916
I understand. Policies and work environment set these situations up to happen. I believe that 100%. I hear you. But in the moment, boots-on-the-ground caregivers like nurses must make decisions regardless of policy to protect themselves and their patients. Let this case be an example of the wisdom of taking a stand that policy be damned, I'm monitoring my sedated patient, and if the pencil-necks in the board rooms have a problem with it, let them fire me, I'll find a nursing job elsewhere and good riddance to them for me. I know it's a scary thing to think about - standing up to the wigs and risking your job, risking your paycheck needed to support yourself and your loved ones, but it's a must sometimes. And I've found that when as a nurse I honestly talk sense to my coworkers and to my superiors, I don't get fired, I get listened to.
I'm not attacking Daronda. She'll suffer the consequences of her actions and I don't need to add to that. I'm willing to guess that the patient was unmonitored at least partly because of staffing pressures and assorted issues. That's sad.
As for putting nurses in situations where they have to override the pyxis, Vanderbilt should go down for that. They knew the nurses were doing it therefore they were responsible.
And as for nurses being held criminally liable, I'm okay with that, particularly in extreme cases. However, where the hell is Vanderbilt's criminal liability? If anything, Vanderbilt's policies, if they led or contributed to a death, how could they not be liable? Vanderbilt's responsibility here, you could argue, is wider and more far-reaching than Daronda's. I'm unaware of the details of the case, but is Vanderbilt being held criminally liable? Are the policy makers in need of criminal defense attorneys? I think we'll see safer policies when we start holding the wigs criminally responsible, too, not just the nurses.
I keep going back to the problem of business-model healthcare. It needs to stop. As does the faulty notion that healthcare can police itself. It obviously can't. And if nurses are to be held criminally responsible in disastrous cases, hold the hospital responsible, too.
There are some serious problems in our healthcare system. While Redonda made a series of grave errors, the hospitals actions afterward are reprehensible and almost guarantees this will happen again. I want to see them punished but feel it is unlikely.
Hospitals are also profitable businesses.
Killing defenseless patients isn't good for business or the financial bottom line from lawsuits.
I don’t trust hospitals, especially after c19 happens. They don’t have the care they always had and are tired and overworked and don’t like people coming in for “a cold”
Why were not two nurss checking the medication against the doctor's order before it was administrated to the patient? It was a tranquilising drug that should have been checked by two nurses,the mistake would have been noticed then and the proper drug administrated.
@@yvettevernet4759 Absolutely agree. The industry I work in regularly implements a two party buy off for inspection points that are not at all life threatening. I would think this has to do with hospital policy. I also wonder if part of the series of mistakes Redonda made were related to stress, overwork and exhaustion. That is something I regularly see everywhere now.
@@jen30551 Could be that she was stressed but if the policy of two nurses checking a drug that would be administrated intraveinously as a tranquiliser had been implemented this terrible mistake would no have occured.
I think you left some parts out. #1 Radanda was a new nurse of only 2 years yet was already training another new nurse.#2 The area where the medication was given did not have a scanner#3 It was not hospital policy to stay with a patient who had been given a medication like the one ordered. #4 She didn't leave the patient alone, she left the patient with the technicians, and they told her it was fine. #5 The dose she gave may not have even been lethal, and due to the cover up by the hospital no autopsy was done. They tried to prove she gave more than she admitted to by using evidence that the hospital (the hospital that lied continually) had kept for a year before authorities took it into their possession. Anything could have been done to the evidence during that time.
Your #5 point is one that I considered: the dose for Vecuronium is 0.1mg/kg, now a lot of assumptions have to take place here, but assuming she did her due diligence and gave 2 mg Vec instead of 2 mg Versed (a common sedative dose) the amount given wouldn't be therapeutic to achieve paralysis, at least not completely, as this would have been a dose for a person weighing about 45 lbs. Despite even that, so much went wrong here, and a life was lost, tragically...
Hospitals have nurses with a few months experience training nurses. Scanner does not matter. Meds are supposed to be read with human eyes whether scanned or not.
@@ronn68 New nurses should absolutely not be training new nurses. That is dangerous. Human eyes fail. Also, why are people acting like she made a conscious choice to not check the med? I've written a paper and proofread it only to find several typos the next day. Why? Because your brain fills in the gaps. How many times have you left the house and thought you left something plugged in? How many times were you right? Or, have you done that same task so many times you went on auto pilot and that's why you don't remember? Have you ever driven home and not remembered how you got there? Again, automatic auto pilot. It happens when you do familiar tasks. That's why they should always have a backup systems that check for errors.
The technicians didn't check up on the patient. Plenty of the blame can go around to the technicians and administration. Plus it should not have been in Pyxis in the first place.
@@CoffeeLover-mz7bk i think the techs were outside the imaging area….behind the glass divider to shield them from the mri or ct scan in process.
her employer is as guilty as she is. I'm a pharmacy technician, if we override the computer it has to be double checked and signed by another employee, any non-compliance would be flagged in a monthly audit.. seems that nobody was taking responsibility (including her)to protect the hospital, the employees or the patients. It's very scary that some institutions run with such a disregard for basic safety guidelines.. I don't understand how they legally maintain a license
Exactly. I think her employer is more at fault than even she is.
@@Nan-59 yeah, employees don't make the rules, they just follow them and if nobody enforces them... Exhibit A
I would run so fast from an employer that irresponsible.. rather than risk my own butt
Okay so you are bias that’s why u didn’t sentence her hope she rots in prison
Vanderbilt is a "teaching hospital." There's a wider berth for mistakes in those places than in hospitals that don't work with students on a daily basis.
100%
As a retired registered nurse that witnessed many EGREGIOUS nursing errors, my experience was that the medical institution covered up these errors EVERY SINGLE TIME. It was despicable.
The thing that upsets me is that while the nurse is facing prosecution, Vanderbilt who is also responsible is essentially getting off scott-free. Our justice system needs better ways of punishing companies that behave badly.
I’ll accept the necessity of criminal prosecution of the medical community when criminal prosecution is just as eager and capable of convicting Vanderbilt as it is to prosecute Radonda Vaught.
My fear is nurses will become scapegoats for hospital corporations.
They already are
@@calmbeforethestormo4136 I wish I could upvote this a thousand times!
@@calmbeforethestormo4136 Yeah they are. Giant corporation fails to protect their patients, and hides it for months? Blame the nurse! But only after there's publicity, and fingers start pointing at Vanderbilt.
Doctors just go to another state to practice ! This nurse was crucified !
The medical big wigs from the WHO and down to the family doctor are killing and injuring people by the 100s of 1000s and yet they are not being prosecuted.
I’m a nurse. A lot of drugs are similar in name. They teach you the five rights. Right patient, right drug, right dose, right route, right time. There are many factors that contributed to this error, but it does come down to actually reading the drug name and identifying the patient old school style.
Seriously. I agree. I mean, read the label on the vial. OMG.
exactly, where was her duty of care, the hospitals policies and procedures? she ignored the very basics, as Mark said, she deserves all she got. she is a disgrace to nursing, as is the hospital......that poor poor patient.....xxxx love to the family, In Australia she would have been ostracize rather than supported, and jailed. surely no professional person would support such negligent actions.
@@lorrainemoderate2816 i think what she did and what occurred is horrible and ridiculously irresponsible, but not criminal???, there is no intent to cause harm, the hospital did all it could to hide the facts from the authorities and when it finally comes out they throw her under the bus AND only then make changes to their system that helped cause the problem,
Those 5 R's are a sham, you do not have time looking at your 5 R's when you have 7 to 20 patients to medicate and 5 of them are crying, the other 5 patients are complaining of nausea and your phone keeps ringing and families and your CNAs keep asking simple and stupid questions over and over because they don't want to be responsible with their answers and want you the nurse to be the person responsible for all kinds of issues from toiletries to the toilet functioning to everything under that building.
@@sandan778 Yes, you MAKE the time....it's THAT important!
A nurse saved my life by questioning a doctors order. Thanks to her I am alive and well today.
Ironic, this nurse could have saved a life by following a doctor's order.
She may saved the doctor's career too. My brother in law is doctor and I don't know how he does it. ONE decimal point off, misspelled medication names etc can kill someone even when a doctor is normally competent. Glad you're here today. My grandmother was a nurse, they really run hospitals.
@@CrowsAreMurderto be fair, in many other fields of work if you're off by one decimal spot, some stuff is going to be really messed up lol
So sick of big organizations covering up crimes. We teach and expect _kids_ to take responsibility for _their_ mistakes, accidental or purposeful, but adults go and do the opposite. You said precisely what I would have said about this situation. I wish I could give you a great big hug for understanding how I feel! Love you, Dr. G! 🤗
Yes! Do as I say not as I do does not work!
Should have been planned procedure by anesthesia
This
Drugs, not hugs, weirdo! Haha
Unfortunately, this is how kids *used* to be raised. So many kids now have parents, teachers, and society at large making excuses for their poor behavior and performance and everybody gets a trophy just for showing up. I’m not surprised that adults don’t take responsibility for their behavior… their parents blamed the teachers for their kids failing!
Poor Charlene … killed by a nurse who made multiple mistakes. Thank you for bringing these details to light.
As a nurse it's unfortunate the hospital didn't also face legal responsibility. I understand she made multiple mistakes however the hospital walked away Scott free.
Edit: reaching a settlement with the family isn't justice
Hospital's cover up mistakes of all kinds because they will not hire enough nurses, nurses are the bottom of priority of their budget. Nurses need a strong union. They hire the newest RN and fire or "get rid of" longer employed nursed because it is cheaper. They don't care about patients, only the bottom line-their profit. Wonder if Vanderbilt still makes their RN as the unit housekeepers.
A settlement with a Gag Order. But the "for profit" hospital is totally innocent. They're about as innocent as their faulty epic system and pyxis. Bet her armband (that she didn't have on) would have been 1 of the many road blocks that could of prevented this. The nurse does carry some responsibility but she was also in a perfect storm that she shouldn't have been due to the failure of our medical system and society, people that have no clue what they're talking about are happily willing to stone her as they make her the scape goat. You know what I find the most disgusting? The fact that the leaders of this hospital, the owners, and all the other rich elites that have the slightest connection to this know what they did and they know what they're doing. They are going to keep shoveling out $$$ for the best PR, legal staff and media relations while they keep profiting and people keep dying. This is only the tip of the iceberg of what's been going on the past five years. I promise. Anyone not in the know, your ignorance IS bliss.
@@misstuxbrandi who knows if there is even a scanner down there. It should have been rescheduled like they originally were going to instead of a doc writing this order with no monitoring for last minute anxiety
The nurse was involved in the cover up as well as she didn’t report the hospital.
Yes, it is the elephant in the room.
The 3 checks: 1.) Check the medication with the patient's record 2.) After preparing the medication 3.) At the bedside after identifying the Pt using 2 identifiers
The 6 rights to medication administration: 1.) Right Patient 2.) Right medication 3.) Right dose 4.) Right route 5.) Right time 6.) Right reason
- being consistent using the 3 checks and 6 rights saves you from this nightmare
As a retired registered nurse, I totally agree with knowing the 5 rights! This was HAMMERED into us as students and on the state boards of testing to get your license. Pure neglect of not following standard protocols! This is sad all the way around!
The medical record was not available. Plz see Nurse Liz episode regarding this case!
Can there be a check where you tell the patient which medication you intend to use, and show them? I’m not a nurse so I don’t know how this would work out in the long run.
@@saysHotdogs You can always ask. That is your right.
This is the most objective analysis I've seen regarding this case.
I agree! Lots of other people have an agenda or discuss this case using emotional reasoning.
The patient should not have been left alone for thirty minutes whether she was given Versed, or any other medication of this nature. She could have been put on Oxygen and been put on a vent temporarily.
All the other mistakes that were made were very much negligent in safe nursing administration of meds.
I am an RN and have given Versed many times.
Vandy patient here, and i have to agree Vandy is partly to blame. I was also given the wrong drug at Vandy... AFTER my bracelet was scanned and everything. There were definite procedural problems. I often feel a bit guilty for not sueing them when it happened to me.. but i felt SO sorry for the nurse and when the hospital administration met with me i was in a vulnerable state, and they may have taken advantage a bit. I felt guilty suing, but now guilty for not
She was honest and upfront about the situation. The hospital swept it under the rug. If she's criminally culpable, then the others involved with the cover up should be prosecuted as well.
We're constantly short staffed at the bedside and asked to do the impossible with limited resources. This is a complex issue that doesn't deserve one person being scapegoated like this.
Sauce: I'm an RN, practicing for 6 years in the acute care setting.
Yes! The hospital pushed the blame onto her once their funding was threatened.
No. She didn’t. She hide the case for many years and found a new job. She said just to the hospital administrators only.
Had this happen to a family member. Over dose of heparin. The nurse denied the mistake and I went ballistic and to the top of the food chain in that place. Already in a very compromised health situation, this would had been lethal for this person had I not been there. Don't be afraid to ask what it is and how much. It might jog someone's mind and avoid a mistake.
Yes! Much of our health care has devolved into our own responsibility!
Every patient needs an advocate even if it's their own family or friends.
Very good advice 👌
Oddly, I see a lot of overdoses of Heparin. I'm unclear why that particular medication is overdosed.
RN here. Please, never be afraid to ask what is being given/done to/for you or a loved one in any health care area. I want you to ask. “The doctor said I don’t have to take the red pill any longer” sends me right back to the order to double check again. That’s a win-win. You win because you get the right treatment. I win because I didn’t make a mistake and possibly harm you. Ask. Please.
Dr Grande, I cannot express my gratitude for your videos. I’m in hospital for a month. My chemo isn’t working, so I’m getting a bone marrow transplant. And I have to stay here for at least a month. That prevents me from getting sicker when I’m in an isolation room. So I’m not exposed to any germs. I was just crying so hard. Then I saw u just posted. I know I sound lame, but the humor u have also helps boost moral.
Thank goodness that my medical service dog is staying here in my room with me. It’s helped me so much. And my daughter comes 3 times a day to take Jake outside to potty. She also brings me things I need. I feel so blessed to have Jake. And your humor also cheers me. I would have fallen off the deep end if not for Jake and UA-cam. This is the lowest time in my life.
To add to things, my grand daughter was born with DIPG. She passed away 2 weeks ago. Then my daughter took her own life cuz she lost her daughter. Every small thing means so much to me. Right now I’ve lost all hope. I also feel that we shouldn’t ever ever waste time at all. Missing opportunities to spend time with loved ones, well it only leads to guilt. I would do anything to spend one more minute with my loved ones. So I’m working on not losing any opportunities to spend time with loved ones. Because that alone makes me feel so useless. That’s why I’m so grateful for videos and time I can spend with the family I have left.
To I thank u so much. It’s a lonely life.
And to add to this story, I worked as a RN and then BSN at Vanderbilt. I also knew this nurse. The best way is to say she is an EX nurse.
She seriously was very strange. I’ll tell u more if anyone wants to know. It was so clear that she wasn’t right upstairs. I feel that she needed a strong antipsychotic and to be locked up. She felt she was above the law.
So extremely sorry for your losses! 💔 May the Lord console and heal you!
Your words are very true!
Hugs🤗🙌🏾
I hope everything goes well for you. Best wishes from me, and Australians.
Her actions seemed murderous To me. Not a mistake. Even so , may she find mercy. As with us. May your hospital room be a veritable sanctuary for you.🙏🕊🙏🕊🙏 Healing Blessings!!!
@@brigidroche1006 thanks. Without my service dog, I would have flown the coop. Lol.
this error is her fault how awful for that patient. I hope you transplant goes well my sister had it done .and is doing great.
Retired RN here. Every patient needs to have a family member with them at all times ( if at all possible) while hospitalized. Ask what medication is being given. Stay abreast of what medication the patient is to be given. My husband was recently hospitalized. His MD discontinued his blood thinner b/c he was bleeding internally. In comes his nurse about to give the blood thinner! Nurse argued with me that blood thinner had not been discontinued (while my husband was receiving a unit of blood due to the internal bleeding)! I told him (the nurse) to contact the doctor & to squirt that blood thinner down the sink. Nurse was indignant. This hospital made visitors leave at 8:00 PM. Before leaving, I found that nurse at the nursing station. I told him to make certain that the night nurse knew not to give the blood thinner. Be there, & advocate for your loved one! Any good nurse will welcome your concern & work with you to insure safe care for the patient.
My gosh, all I can think of is how much this poor elderly woman suffered! I watched the interview with this nurse, I didn't see any remorse, nothing. I'm glad you covered this one Dr. Grande 😊
I was an ICU nurse for most of my career and also did conscious sedation for a few years with the drug versed. I also administered paralytics and sedation while people were on the vent so I know any paralytic is brightly labeled with red labels and has multiple barriers to get into it. At the very least anytime you give an IV sedating drug you need to assess immediately for effect and come back within 10 - 15 minutes to reassess how the patient is doing. The effect of vecuronium is almost immediate and should have been noticed. Initially I was ambivalent about this when I caught the end of the trial and heard Ladonna speak to reporters but I hadn't known which drugs she mixed up. Now that I know more details I do think it's right but I don't know that eight years is appropriate. Med errors are most often caused by systemic failures but bad nurses can eff it up all on their own once in a while. The 2 neurosurgeons should also get a ding against their liscences for lying to the medical examiner. I hope JCAHO cited the hospital also.
I agree with you 8 years seems egregious and was an overcompensation by the State after the publicity associated with this case. It was truly a horrible way to die by being given a paralytic and I am not sure why it wasn't immediately noted when she became apneic and unresponsive. I am assuming she was going for an MRI, but she should have been observed for medication effect even if the nurse had thought she had been given versed there is still a risk of respiratory depression.
As a critical care nurse, I agree with this the most. I can't say it better myself.
@@kitchenskills5427 And there were no techs in the imaging room for 30 minutes. They're the ones who found her. She died alone and probably terrified. This horrible death was not just caused by 1 nurse, but a system built to fail and then hide its mistakes.
It was 2 neurologists who certified the death from a subdural bleed .
Why did the patient need a PET study?
@@charlesdarwin5185 I guess to find the subdural bleed that killed her? JK they lied for the hospital so Vanderbilt could hide it.
I have lived in Tennessee, and I would rather operate on myself, than to ever seek medical care there again.
Are you accepting new patients? What insurances do you accept?
I was going to say I don't remember Vanderbilt ever being regarded as a model hospital. I could not tell if Dr. Grande was being sarcastic or not in his intro.
Absolutely good analysis. I'd also love to see the hospital get charged for the negligent cover up.
I have argued with many nurses on this topic and they all seem to not be accountable for negligence . neither do cops. i argued them to resign if they could not administer the right drugs and double check before doing so.
@@tankthearc9875 ok Karen
That’s the thing, though, they won’t be, neither will any of the doctors who covered it up. This is the actual root of the issue.
It doesn’t matter whether it’s engineering, nursing, whatever. Higher ups never get held accountable, it’s always the lower level employees who do, despite the fact that often the culture pervasive in their work environment is the catalyst for mistakes.
they get fined by CMS, and its usually a hefty fine. At our hospital a PREGNANT RN was allowed to hang an anti-cancer drug which is a no no. The hospital was fined $10,000.
@@pedinurse1 Screw paying penny fines. Every single person involved in this coverup should be removed and charged.
Excellent analysis. She should not be exempt. It’s too bad that the laws don’t apply to law enforcement.
I am a retired RN and I am appalled at how many times this nurse had an opportunity to rectify her original error and she did not! This is more than sloppy, it is criminal.
You've helped me sort through my own opinion as a layperson regarding this case.
@@deborahmulkey1627 It is absolutely insane for vecuronium be placed next to Valium. That is a mistake waiting to happen and unfortunately it did
@@kathleenbueter1272 *Versed* but end result was the same.
@@deborahmulkey1627 100 percent one can’t hope that technology is in placed to do all of the work. You still have to understand what your doing and know that there is a chance of mistakes.
Am I the only person that thinks perhaps the orientation process had something to do with it. Like when management tries to use an oriented as counted individual staff?! This case stinks. The error was so flagrantly avoidable. Or did this nurse have a drug problem the hospital wasn't dealing with. I feel like there is more to the story we haven't heard.
Why is the nurse the only one being held accountable? The hospital and its’ systems failed her and the patient. Redonda immediately reported what happened. Then the hospital covered it up. Who is acting criminally here?
What else could she do but report it? The woman was dead. There was no covering that up. But, you are right. The hospital is responsible as well. That was why they were sued and had to pay a settlement.
Yes, but hospitals are corporations. They are protected from the consequences of their actions. Besides Vandy is part of the historically spotless Tennessee government. And she is only a nurse, and individual ,where are your values?
She killed someone end of story
As a practicing nurse i completely agree with the point of view presented in the video. Someone who is capable of making a series of such errors should not be a nurse, especially an ICU nurse where patients are particularly vulnerable.
I was a nurse for 35 years.
Police and nurses should not be protected from criminal prosecution. The majority would never have made those mistakes. Having the power of life and death over others carries a heavy burden. If the consequences of your actions is more than you can shoulder then choose another way to make a buck!
@1960ebutuoy, excellent comment, thanks.
Agree!
What kind of nurse were you? Registered? Specialty?
I think Radonda needs to take responsibility for this, she said it herself. However, I disagree with your somewhat cynical take on the nursing profession that hospital mismanagement makes them feel at liberty to not pay attention. In my experience, nurses are much more worried they will take the fall for doctors and administrators' mistakes, rather than the other way round. For example, it is common for on call night shift doctors nearing the end of their hours to put off care so that days shift will have to deal with a given problem and they won't have to come in the middle of the night. If something happens as a consequence of this, it's more likely to be pinned on nurse complacency or miscommunication than physician irresponsibility. Things like that happen all the time. Most hospitals are understaffed and nurses are often expected to take unsafe patient loads, pick up mandatory overtime hours, and work in environments where cost cutting and mismanagement make it difficult to operate safely. This is far from the only hospital overseen by the type of corrupt individuals who tried to cover this whole thing up. Rather than complacency, the nurses I interact with go to sleep terrified that tomorrow is going to be the day when, overstretched and exhausted, they make a mistake such as this. Ultimately, Rodonda made a terrible mistake which she must live with, but it's plausible to say that her managers created an environment where mistakes were much more likely. It's a crappy situation, no doubt. It's also crappy that the corrupt admins who did illegal things (like ask nurses to override safety protocols in the medication cabinets and hide negligence from the police) seem to be facing no responsibility outside earning a bad reputation. Correct me if I'm wrong. Radonda needs to take responsibility, but more investigation is needed.
How do you NOT read the complete drug name or see the big warning color that says paralysis though. That's on her.
@Rocky I don't actually disagree - she made an inexcusable, idiotic mistake. The problem is that hospital administrations often make an environment where these sorts of errors are more likely. If nurses are doing (sometimes mandatory) overtime you could easily have someone coming on for their fourth or fifth 12 hour shift in a row, assigned more patients then they are supposed to who all need meds at certain time intervals or they will get more sick. Admins at this hospital apparently were illegally telling nurses to surpass some (to be fair, not all) of the safety checks on the drug storage machines essentially to save time and not have to hire more people. It's still ultimately her responsibility, I'm just saying there are plenty of people worth criticizing here.
So true that it’s a problem with the hospital and staffing.
We need a better system for sure. Yes. This nurse was grossly negligent. But these Pyxis dispensers have way too many warning so it becomes routine to bypass them. And the Pyxis system bypasses the check and balance of the pharmacist. Is that really appropriate for drugs like Vecuronium? Also, did the doctor order Versed electronically or was it a written or verbal order? Because when we have the nurse transcribe the order, get the medication out of the Pyxis and administer the medication, that’s just too many steps without any check and balance.
Look how the public used nurses as a human shield since the beginning of the pandemic.
No one is standing up for nurses.
What a tragic and horrible death, and after listening to your video- what a inexcusable amount of mistakes that were made!
I so agree with your comment "The RaDonda Vaught case is not a good example of a case that should have been ignored by prosecutors."
Also really loved your final thoughts, Dr. Grande!
Of course she should have been charged. Like bad drivers that don't pay attention, are reckless etc, kill people on the roads.
Imagine a delivery driver saying "but I didn't intentionally kill that pedestrian" - well, that's nice, but you shouldn't have ran the stop sign, while looking at your phone and driving on the wrong side of the road.
It's not the same as if you're doing everything right and somebody jumps in front of your van and you run over them and kill them.
It does matter if you intended to do something or not, but that doesn't mean you're now suddenly not responsible for your actions.
You still messed up, you're still guilty of causing death to someone, who is innocent in that scenario.
You have certain responsibility, you can't just say - "oh, stuff happens, nevermind. Now get off my back, otherwise other professional drivers will be afraid to drive their vehicles, because if they kill someone unintentionally, they might be prosecuted too".
I am an RN. The "system errors" that were in place before this nurse pushed the med are glaring. This is a sad day as med errors will now go underground and will never be resolved. So sad that it's, "Always blame the nurse."
I can’t get over how they had to ‘train ‘, their nurses to subvert the electronic double check system. I heard elsewhere that that’d been going on for a LONG time. There’s no way to tell what her work load was that shift, where else was she expected to be at the same time. She owned the mistake the hospital hid their culpability. That place should face severe penalties.
It is said that nurses have to use 32 technology workarounds during a 12 hour shift just to do their jobs.
The public used nurses as a human shield from the beginning of the pandemic.
Here comes more documentation!!
Nurses will bear the brunt of extra work. Check with 2 other nurses before giving? Have the unit manager check every med?
@@ean5469 My favorite ridiculous check is "check with the doctor or pharmacist" when there is one nurse, one CNA, 20 patients (many of which are fall risks), annoying family members everywhere, and the management threatens to write you up and/or fire you if your meds are not passed in time.
I agree. This was inexcusable negligence that warrants a conviction. People who are that careless shouldn't be allowed to practice medicine
I was so hoping you would cover this!!❤️ I have worked with other nurses who have done this type of thing before!! I can understand once, but this was her second time doing this. She was fired from her previous job for the same exact thing and she had only been a nurse for two years. She’s not the only one a fault here either!
Yes it is insanely common, and sadly rarely properly addressed.
As a Registered Nurse who has been in this business since 1987, I can tell that you have no idea about conditions in hospitals nor the extreme pressure that nurses are under. I am not defending this nurse’s actions whatsoever. I would like to see a video from you showing the dangerous understaffing of hospitals all over this country. Apparently, the general public has been kept painfully unaware of the national nurse shortage and the dangers associated with the shortage.
It is by design this is happening. Hospitals are big business here and they decide on what is reported. I am positive many politicians and news companies have agreements with these places.
I can't agree more!
Where is the psychiatric analysis of health care workers being forced to work in understaffed hospitals routinely? Air traffic controlers and preschool teachers have govt mandated stafty ratios. What about the patients? Safe staffing matters for patient safety.
@@jenniferr4364 corporations run private hospitals and they will squeeze the most work out of healthcare workers without worrying about consequences. It is all about the profits and pleasing their stockholders.
I work at a med/mal law office. Medical "mistakes" happen much more than you would expect.
Dr Grande,
I love this analysis. I would compare a nurse who kills someone with a medication error, and no follow up, to a peace officer/police officer who accidentally shoots someone.
Yes accidents happen, but there are accidents, and ACCIDENTS, which could basically be prevented, with a slow down and think moment.
When you choose a career, making yourself responsible for other people's lives, you are then responsible.
Thank you again for these great analyses.
Love from (the still snowy) Canada 🇨🇦
One further comment. Vanderbilt covering it up most be a common theme.
Everywhere our local serial killer, Elizabeth Wettlaufer, worked, they covered up her bad behaviour. She was allowed to move from place to place, abuse drugs at work and be caught, make many medication errors which she was fired for, kill 8 people with insulin like it was nothing, injected how many others, and would never have been caught until she voluntarily confessed.
She never lost her nursing license for all her recorded bad behaviour; although it was suspended once.
As a retired ICU RN for 40 years - I can tell you that the paralytic administered to her rendered her helpless to move anything, including her diaphragm, and she had full consciousness through most of the time it took her to smother. Question - video says she was a "licensed " nurse. Is this an LPN or an RN? There is a big difference in responsibilities. Absolutely NO LPN should be allowed to give Versed.
RN, 2 yrs experience, no patients that day, no stress per her own deposition, working as a help nurse, and Teaching a new nurse!
No r.n. gave the med.
A R.N. GAVE THE MED.
I’m a nurse and I agree with the charges. There were too many safe guards in place that she completely neglected and then didn’t even monitor her patient afterwards is unacceptable as a nurse. Her main job is to monitor change and she failed on everything in this situation.
i can tell by your statement you most likely are in management and not a bedside nurse
As a registered nurse, I can tell you that you are taught in nursing school from day one to READ the medication label SEVERAL TIMES before administering any drug. You also have to monitor the patient. She should lose her license at the very least. The hospital needs to be punished for their part. With that said, nurses are often given dangerous patient loads that will cause more errors and neglect. I have no idea if that was also a factor, but this nurse was acting in a dangerous manner.
You are the best commentator on line. Your voice is so expressive and measured, very easy on the nerves no matter how horrible the case. You also have a delightful dry sense of humor. Please keep on commenting on the cases that no one else can make sense of. I am a fan!
Taking the erroneous medication out of a "Documed" type of dispenser is one thing. Initially I had fortified the nurse, but as the facts kept emerging, it got worse. One of the cardinal rules of administering any medication as a nurse is the
"Five Rights" or the "5 R's"l
1. Right Drug
2. Right Dose
3. Right Time
4. Right Route of administering
5. Right Patient
She mentally conceived she was giving Versed, she should've checked those rights twice, let alone giving Vercuronium. It's not rocket science that you should follow these guidelines. Every instinct in her should have ceased her.
However, the cover-up Vanderbilt orchestrated and executed, is nothing short of horrible. From the CEO down, they all should be held accountable for being an appendage. The family being able to be bought off for their muteness is revolting and Vanderbilt is a Despicable hospital.
I agree 100%
And just think how many get away with it.
@@ev25zv Absolutely!
You "fortified" her??? 🤔🤦♂️🤦♂️🤦♂️
@@jessetaylor7951 Fortified means to strengthen, encourage, secure. The hospital not reporting the incident gave that nurse the strength to move on without consequences.
Finally, I hear someone speak some sense! I've seen so many nurses on social media stick up for the woman and it terrifies me! One mistake fine I can understand, but she multiple serious errors. My father fell at home and was taken to the hospital. Someone messed up his medication at the hospital. He had to be resuscitated and was in the ICU on an intubation ventilator for a few months. We didn't know why he was in the ICU for a fall until he was released from the hospital and the family doctor told us what had happened (apparently it's the procedure?). It's been about 5 years now and he is still in a wheelchair because he never was able to walk again.
Dangerous people shouldn't be around vulnerable people.
Yeah, Vaught lost me when she didn't scan the medication and patient's bracelet barcode. It's mandatory to use the bedside medication verification specifically to avoid situations just like this.
Totally agree. I’m a clinical lab tech. I could understand one or even two of the errors she made but by not even attempting to verify the patient’s identity with a simple barcode scan, she lost me. Like I’m having a hard time not thinking there’s more going on here.
Except when the hospital does not provide this equipment. There were no scanners in Radiology when this happened n
The scanners were not working. That is why nothing was scanned. This safeguard would have prevented this tragedy.
Two separate hospitals I have worked at do not have scanners in MRI. That's an easily preventable system issue.
Okay - I based my comment on the information presented here and Dr Grande said at 8:35 that Vaught did not scan the medication and patient's wristband (implying that she could have).
That nurse just made too many mistakes.
Agreed, at some point the negligence just becomes so gross/reckless that it does rise to the level of a criminal offense. Especially if it causes the painful death of a vulnerable, elderly patient.
The hospital also should have had better oversight and safeguards in place.
Thank you for speaking sense. Every nurse is saying this will set a precedent, but don’t talk about how negligent the nurse was. You can’t blame stress or a place being to busy for a death of an innocent person
yeah, that list of things she had to ignore to make this mistake was pretty damning. ignoring that many warnings and procedures, but having enough presence of mind to perform an override? how can that happen?? she's dangerous
I'm wracking my brain about this. I'm wondering, and there is still definitely fault on the part of Rodonda, if she and her orientee were used as separate staff and thus she was counted and they were separated. I'm wondering if the orientee made the error. Hospitals routinely try to take nurses prematurely off orientation.
The drug that was supposed to given is never reconstituted. Just the fact that the med needed to be mixed would give any nurse pause, enough to call pharmacy or at the very least another nurse.
I realized seeing pictures on another video something I had forgotten, versed is always in a brown bottle. It must be light sensitive.
There are problems with the med dispensing systems, but a nurse who works in ICU would know to monitor a pt and not leave the pt. The pt should have been on a monitor in the machine! I had heard the nurse was called away to the ER.
The hospital attempted to hide this event. Perhaps the idea is to trial this nurse to open up testimony to further prosecute the hospital? I don't even know if that's a thing.
This case comes down to a nurse misreading the label, and the hsopital not having a scanner that worked. They claimed they fixed it but it was not fixed. Now I'm not defending the mistake, you can't throw nurses and doctors in jail when they make every mistake, all nurses and doctors would quit because it's just not possible to never make a mistake in your job. Lets remember your asking for people to be absolutely perfect all the time. Lets try to remember she had never previously had a med error and she reported herself.
I needed to read your response. Glad I did. I was texting my outrage to the analysis and saw the word in your post that calmed me down. The word is "gross", gross negligence. I have had and have heard of close calls but never to this extent. The governing bodies need to ask about the elephant in the room. Why did she show such gross negligence? There are a lot of "Whys". We all need to ask why did this happen and how can this be prevented in the future. Will nurses become lees forthright in reporting incidents? Why? or Why not? So far a response to the whys only get crickets. It is better to be humble and realize that you have the wrong drug instead of feigning that you know what about a drug. The preceptor seems to be the reason for pushing on. Nothing else makes sense. If that is the case then criminal charge is a no-brainer, but how do you prove that.
Finally some accountability in the medical community
Just a drop in the ocean of their mistakes. But a small victory for accountability.
I've been an RN for 38 years. I assure you that some of us DO try our best, and do not override safety checks as Ms. Vaught did.
My dad is a nursing instructor with a master in nursing. He was an EMT for 30 years and an ER nurse as well.
I asked him what he thought of this case, he said you ALWAYS, ALWAYS double check, triple check and quadruple check the medication before administering it, no if ands or buts about it.
When people's lives are in your hands you have to be hyper vigilant.
When and if, heaven forbid an accident happens you are always upfront and honest about your mistake and take responsibility.
As an anesthetist it disturbs me that anyone without anesthesia training would even have access to Vec or any other paralytic for that matter. It should NEVER happen for any reason. They aren’t taught the uses and dangers of these drugs and therefore shouldn’t be able to touch them.
Why would you, as a nurse anesthetist, think nurses "aren't taught the dangers of these drugs?" Spare us all.
☑️
Lol... You believe general nurse practitioner don't know about vecuronium or paralytic agent in general?
I'm not in the medical field, but I heard the drug she used is usually locked up and the packaging has extra color so it can stand out that it's stronger than most. She sounds like a sloppy nurse. You listed a lot of other ways she was negligent. If you aren't capable of paying attention to details, please stay out of the medical field. I feel for the victim and her family. It was a senseless death 😢
And painful!!
The drug she pulled should NEVER have even been on the floor she was on- it’s a paralytic used to intubate people and only used by anesthesiologist who pull their own meds separately. The medication dispenser where she got the med from was broken and the scanner that verifies patient ID and proper med was broken as well. The physician also made it a verbal order- meaning it wasn’t in the system and he refused to write an actual medical order. Nurses are instructed to follow a verbal order immediately by a doctor bc it usually indicates an emergency- the doctor was the lazy one
@@whalefuhk I also heard that the machine where it was dispensed hadn't been working right. Nurses now need to protect themselves and have it all written which is impossible to do during a true emergency, like someone going into anaphylactic shock or someone having a heart attack or stroke!
No disrespect, but if you work in the medical field you’d know how easy it would be to make this mistake with all the safeguards removed. I have to work with more than one person talking to me at a time and their family on hold, angry because I haven’t picked up the phone. There’s only one of us usually doing the job of 4-5 people.
@@facemuscles9 I appreciate this comment. That's why I wanted to start my comment basically saying the point of view of "someone from the outside looking in". So you're saying it was pretty inevitable for this to happen and would've happened to ANY nurse at that hospital?
You’re the only “true crime” guy I can really watch! I enjoy learning about people and why they do the things they do, and you’re able to provide the facts without making things extra “spooky”.
She is nit a criminal
❤❤She testified 2 hours to TBI without an attorney . The DAused this 2 hr testimony in court against her. Her attorney Peter Strianse was an attorney to a high profile case in 2014 . Vanderbilt football players involved in a gang rape of Vanderbilt coed . Peter Strianse represented Corey Batey in appeal. This was Radondas attorney as well
I recommend the channel Dire Trip. Very respectful, non-fantastical reporting of darker crimes.
@@TanyaRadic she is a criminal.
I just retired as an RN of 45 years. By the Grace of God I never made a mistake like this but,all I can think is: That could of been me. Anyone being so pious is just wrong. There were so many holes in this system that, unfortunately, it made for a perfect storm. Nurses need to unite, not divide. The hospital is the one that should be on trial here. It failed to report the error which opens up for chances of possible increased errors. An out of court settlement with a gag order was made. Now, for some odd reason, it’s brought out again into open and I feel it’s the hospital trying to cover up. Administration knows of RN’s being understaffed yet do nothing about it and know we won’t walk out on patients or an assignment . I was taught NOT to let patients know we are understaffed. We were made martyrs.Why did the hospital not have patient/med scanners? It’s about doing the most with bare minimum. The hospitals will work the medical staff to the brink of collapsing while administration is on holiday in Figi.
Sad,this happens much more often than we can imagine
Oh my goodness. Does it? I hope nurses and doctors will start being prosecuted.
I’m an ICU Nurse, 24 years. This case: disturbing on a lot of levels. Her mistake was bizarre when you compare the two medications. Most people in my business call Versed midazolam. We don’t use brand names. Typically a Pyxis or Omnicell won’t deliver Versed. If you keep pushing the letters VE, the Pyxis says ok, you keep asking for Ve, I will give you VEC. In addition, if all these hospitals keep trying to do more with less, this is what you get. COVID just put the shortages under the microscope. I will say, this mistake…. Unacceptable.
I am a nurse too.
I don't know the whole case here, but you seem to be trying to devalue another nurse to make yourself look better.
@@btetschner so don’t comment if you don’t know the whole case🙄
@@TheIddieMorris I know you are a self-interested person who would betray any nurse given the opportunity.
@@TheIddieMorris Have you always thought of yourself first?
@@btetschner you really don’t know anything and I’m done discussing this with you. Have a good day.
Excellent analysis.
As a non-medical person, I've worked in the medical community for a few years. Cover-Up , is a big thing.
It's disgusting and criminal.
MFR - And the cover-up is almost always uncovered and the error compounded!
The nurse did not cover anything up; the hospital did! The hospital should go on trial.
You are right, It's a super big thing. I have a BSN and I get continuing education course material (and internally they warn/teach that 250,000 patients will experience an adverse event ANNUALLY and over 100,000 will die from care received ANNUALLY) this is something they internally acknowledge is a major problem. That is why so many other nurses went on TV saying she shouldn't be punished harshly.... because they fear similar repercussions for something they know is SUPER PREVALENT and statistically have all done themselves.
I had to leave the medical field because my pointing out all their errors and trying to fix things creates a 'hostile work environment' according to HR
@@SoManyRandomRamblings
Thank you, Random Ramblings for your response.
In the early 70s, I was in a nursing program.
After two semesters I was asked to leave the program. Because I asked too many questions.
Except Vaught didnt lie or cover up-she reported herself! Vanderbilt and their doctor covered it up!
Dr. Grande, I'm a RN and simply put- I agree with your opinion and analysis on this case. I can not EVEN believe how many safety barriers she broke through~ how many errors she made which ultimately lead to killing this poor woman! I just don't get it, not at all. I'm so glad she's not a nurse anymore and the jury got it right.
Dr. Grande, thank you so very much for taking my request! I truly appreciate, and can’t wait to hear what you have to say about this case.
Thank you!💕
Oh what a great request, Rejane! This is a case that represents a lot of what I am angry about with unethical conduct in big organizations. Congrats on him doing it; it's a special moment when you see your request in video form in the notifications! 🤩
@@annal7364 Thanks Anna! Yes, this case has the medical community up and arms. Vanderbilt should have owned the responsibility for covering up this, it’s just outrageous.😣
💐💐
@@rejaneoliveira5019 Thank you Rejane, I get so fed up when mistakes like this, are swept under the carpet.
@@cottontails9003 I agree, that’s the worst! Vanderbilt should be held accountable for their mistake as well.
As an RN in ICU for almost 30 years this whole thing was very preventable if the safegaurds are used! A nurse has to stick to the basics of med admin,=Some take shortcuts to get the job done in todays hospitals with short staffing and more demands on the nurse! Nurses need to be tough enough to refuse to work when safegaurds are bypassed==I have quit jobs where I believed it was not safe for me or my patients== safty systems do not work when Hospitals save money with short staffing!!
This makes me wonder how many other patients she was careless with
I'm a retired pharmacist. I agree, and I suspect that THIS is why she's being thrown under the bus - that we don't have the whole story.
It makes me wonder why so many nurses are supporting her.
Unless you work in a hospital you have no idea what it’s like. That is what is so frustrating. We can’t even began to tell you how it is. I can guarantee that any nurse who has ever treated you or a family member has made a medication error. Most are so small it doesn’t get reported because it causes no harm.
@@Wazupiseeyou because private hospitals don’t care about competent nurses. They just want there stock numbers to go up and please their stockholders. They just want warm bodies in there. When they make a mistake they will throw them under the bus even though many factors go into these mistakes.
@@1019mommy sure but she said she wasn’t busy/over worked and wasn’t stressed. What’s your excuse for her mistake ? She was a floating nurse..
Not only did Charlene die~ but she suffered terribly!! This nurse was not emphatic to her patient. She was totally 💯 irresponsible and obviously nursing should not be her career. Glad the situation came to light. That patient was ready to go home before she suffered and died🤮😡😭
I admire how you articulate the facts and explain the terms in an organized concise manner in simple terms and of course with that bit of sarcasm to lighten things up. I also appreciate how you share your thought analysis at the end to provide moral perspective. Your platform is a great service to many in understanding “the system” and human nature. You’re right this was a very sad case of lacking principles and accountability for the nurse and organization
You are so Awesome 🤩 Dr. Grande! Thank you for all you do!
Vanderbilt hospital shares the responsibility of what happened to this patient. First they were having problems with the mechanism, second why was vecuronium put in with Versed? Vecuronium is clearly an anesthetic agent. No anesthetic agent should be put in a cabinet with Versed especially right next to Versed.
In my electronic med cabinet vercuronium is stored in the kit labeled ‘rapid sequence intubation’. There’s no mistaking the danger it poses.
I agree! Absolutely! That medication should've never been available. And THAT's on the hospital. Nurses are very overworked. The good doctor here says nothing about that.
@@Nan-59 there are very few places that members of the general public can enter, kick punch and spit on you, then leave with no consequences. Working in hospitals today is a nightmare. If I had a financial exit strategy I’d be done with this line of work.
@@83RBurke In my cabinet Versed and Vercuronium are not stored together. Our rapid intubation kit is under 2 locks.
@@83RBurke that's your choice, it does not excuse these sloppy behaviors.
Looking forward to hearing your thoughts on this topic, keep hearing about it nonstop. Thank you, Dr. Grande! 💜
I have some thoughts on this. First I would say that what is good for the Goose is good for the Gander. I have personally seen things that Doctors have done that ruined a patient's life but lawyers say that it is impossible to sue the bar is too high. Another thing is that not all organizations cover this type of thing up but they are Very willing to throw the nurse under the bus when there are many flaws in the way they operate which led to the mistakes. Number one is insufficient staffing compared to the patient load.
Thank you for this video. I hope it reaches at least a fraction of the nursing community who have embraced this nurse and defended her gross negligence . I am, of course, deeply disturbed at this nurse's obvious gross incompetence and being portrayed subsequently as a " victim" herself-- a portrayal which she seemingly accepted. I am deeply concerned with her apparent lack of genuine acceptance of her responsibility in the suffering and death of this patient. In my opinion, the prosecution and conviction of this now- ex nurse was just, fair, and necessary.
The attitude of a substantial number of nurses regarding this case- as demonstrated via social media-- is disheartening to me. Some demonstrate such a low level of basic reasoning in excusing her actions as " an honest mistake" ( whatever that is), that one should wonder how they themselves are functioning. They cannot see that-- obviously-- " the healthcare system" indeed, cannot police itself.
Then there is the morality of the collective nursing community. The arguments made in support of this nurse include this perhaps pathological belief that she has been made a scapegoat of a massive corporate healthcare system. While Vanderbilt Hospital did indeed have some obvious flaws and willfully engaged in a scheme of deception after- the-fact, no hospital administrator took a paralytic out of an automatic medication dispensing machine, ignored the warning, reconstituted a drug (that any neurological ICU nurse would know did not require reconstitution) etc. No administrator injected this medication. No administrator failed to observe Mrs. Murphy for the effect of what was believed to be a sedative. Only this nurse could be held accountable and responsible for these actions. Further, many nurses claim that this case will cause nurses to not report their errors. So, what these nurses are stating is that nurses will lie about their medication errors? ( Actually, many already do). That belief demonstrates a rationalization for and acceptance of a reduced standard of care in an occupation that is already compromised by fast-tracked nursing education and the recent depiction of nurses as "heroes"--- which many seem to have taken to heart.
Good nurses who care about the standards of care-- those whom you want at the bedside-- will see the benefits of the outcome of this case. Those who histrionically claim it will cause a mass exodus from the occupation-- perhaps should consider leaving as well.
In my own careers as an ICU and ER nurse, an ARNP, a nursing instructor, an expert witness-- I have learned that the closing of ranks by nurses to protect one of their colleagues is a sign of a flawed collective conscience, if you will. I can only hope that the relatively small number of nurses who justly and accurately comprehend the magnitude of this nurse's negligence will ultimately influence their less aware colleagues.
Your comment was so well-written. Thank you for your perspective as a nurse.
The worst part is the patient was given the diazepam because she was claustrophobic and was scared of being in the CT machine. I feel like that might have been her biggest fear, slowly suffocating to death in a confined space . Horrible. Just horrible. Im glad justice was served .
If she had administered a non lethal drug by mistake--no harm no foul. Same mistake but no repercussions. . What is to be gained by putting her in prison--she no longer has a nursing license so she is no danger to the public.. This is a bad precedent--it's the rare doctor, paramedic, EMT or nurse that on a busy, stressful shift has not made a mistake. Do they all need to purchase individual malpractice insurance and drive the cost of health care even higher. I posit that if the hospital and nursing board had done their job-i.e immediate investigation and disciplinary action, including revoking her license, the person who likely felt like RaDonda got away with this mistake and turned her in, would have felt like something had been done and wouldn't have taken that step. Happens all the time.
This all confused me - as a nurse - I think you hit the nail on the head!
She needed to go to jail she made too many careless errors... very negligent
Omg I’m a retired nurse that was horrible so many errors that poor poor innocent person that lost her life
Doctors are given far more professional leverage in “negligence” situations. They get a pay to play via insurance payouts when they fuck up. This is a labor inequality issue.
💯 Do you know how many patients don't get the care they need because insurance doesn't cover it and doctors are forced to find ways around that. In most cases that leads to the patient not getting the proper care that they needed. I don't know why insurance gets to be the deciding factor on what treatment you receive. It's all about money. It's going to take the top guy to the bottom guy to fix this.
@@moecuspocus because of capitalism.
@@moecuspocus universal healthcare would fix it
@@AMM3. I agree
The worst part about dealing with doctors is they are usually too arrogant to admit they made a mistake... Or God forbid a less educated person correct them, even though that person may have more work experience in that particular area.
I work in the medical field, trying to give doctors advice or correct them is often a losing battle
I’m nurse and I agree with Dr Todd. I also believe that just 8 years in prison it is not enough time.
When I first heard of this case I did not realize how many of the safety factors she ignored! The truth is nurses override the medication dispenser all the time, especially in critical care areas where you need to have access to drugs the pharmacy has not yet released to the patient profile. I could see how in a hurry she would pull the wrong medication but there are so many red flags past that point that she ignored! The fact that she had to reconstitute that drug is a biggie not to mention not scanning the patient's arm band! There have been times when I have pulled the wrong IV solution or medication and the armband saved me! At the very least that patient should've been on a portable monitor when in the CT scanner! What a terrifying way to die! You are right… Hospitals do hide mistakes! I think criminal prosecution is a good thing!
I agree. An elderly patient on Versed sedation should have at least been on a pulse ox while undergoing a Radiologic procedure.
Sooo many nurses are supporting her blindly simply because she is a nurse and so are they. I started doing research on this case, rather than watching Tik Tok videos on the case. Man, she ignored so many red flags. She admitted she was not busy, that this was not urgent. So why did she hurry to give the med? Call pharmacy, have the med verified. I am not perfect. I have had close calls too in my career, but this was extreme. She was an an experienced critical care nurse. So avoidable. She ruined her life. I honestly feel bad for her, but ghis pt died in a horrific way. One lawyer described her death as being burned alive would be the worst way to die, while the second worse way to die is the way this poor woman died.
@@user-pl1hz8pu1p
I know nurses who think she should have lost her license but also think that a manslaughter charge was inappropriate for a medical error. This really is a pivotal case because we have previously seen such cases handled with loss of licensure plus a malpractice settlement. I do agree with this decision but I’m just clarifying because I’ve heard from lots of my nurse friends.
I, too, have been saved a few times by scanning the armband as I should.
@@beagledog2001
I saw another video that claimed that there isn’t an armband scanner available in Radiology at that hospital. It was a doc who goes by ZDogg.
Dr. Grande, I can trust you to be objective and to let no-one off the hook. Two things I appreciate, very much. Thank you.
This is the best explanation of this case that I have heard. I was surprised when I watched the trial that the victim’s DIL said the family didn’t want the ex-nurse prosecuted. Truthfully I wouldn’t have been that forgiving. I’d want the public (possible future patients) to be aware of what happened.
I agree with your analysis. Humans make mistakes, but it does matter when those mistakes are especially wanton. The solution (if there is one) is to use technology to help prevent or alert to such mistakes -- and to automatically document everything that HAS actually happened. Realistically, that will the "best" that we can do.
I have watched med errors happen at a hospital. None that were fatal but , it does happen. When it did, the nurse reported it: the hospital l had a meeting and created new measures to check the medications between the doctors, pharmacy and nursing : and then trained all the nurses on this potential error so that it won’t happen again. That is how mistakes should be managed: review the issue, find out what caused it, prevent it from happening again. Not ignore it. Not brush it under the rug. Because ALL of us will be in a hospital bed someday and we have to know we are safe.
I am a nurse and she violated a basic basic nursing 101 medication pass rule of verifying a medication 5 times before giving it. Being in a hurry or stressed out is no excuse because she is the last safety check in the process even if hospital or pharmacy shouldn’t have it in the Pyxis. She did Not do her job well. Having a student with her should have slowed her down to teach the student to check it as well. They should have talked about the medication as a teaching moment so I don’t have a lot of sympathy for her.
Surely being called RaDonda was an important causal factor...
I wondered about this too. It’s an odd name. I also wondered about the way they treated a 75yo woman. Geriatricians have noted that doctors often discount the value of older patients. Louise Aronson’s book Elderhood recounts a doctor who said he’d have responded sooner to a call if he’d realized the patient was younger. An article in J of Gerontology suggested that nurses are the most ageist of health professionals.
At the hospital where I work a nurse killed at least 4 people five years ago. Så the threat is more real than you think.
The nurse did not cover up her actions at any point. She admitted her mistake to charge nurse immediately, as code blue was called overhead. If she did not say anything, no one would ever know, paralytics dissipate quickly, there would be no reason to suspect anything. Literally, the ONLY REASON this is know is because she admitted her mistake immediately. As for the monitoring the patient, she was told to leave by the MRI personnel, she was told that they would monitor the patient. Also, the only way to truly monitor patient in MRI is to have patient hooked up to MRI compatible equipment that can stay inside the room. If patient did not arrive on transport monitor (as ICU patients are always travel with ICU RN & monitor + the drips), it is not a routine practice to place patient on the monitor, even if meds are given. The hospital cover it up, even when nurse told the truth and admitted her mistake immediately. Mistaking one med for the other, holly sh!t, they are nothing alike, it does not even say Versed on the bottle, it midazolam. The hospital does not even get a slap on the wrist for this cover up! She made a mistake, admitted to making mistake, paid for it with her job & license, and now prison time, but ever happened to the hospital? Maybe, just maybe, someone should look into how they operate, maybe find a few doctors who made a fatal mistake, and absolutely nothing happened as a consequence.
You've made some excellent points that no one else has mentioned.
She didn't admit it right away, though. And she didn't just make a mistake (or even two) -- she made a series of surprisingly negligent decisions. The machine warned her like 8 times and the medicine label had a big "paralytic medication" warning on it. She then left the patient alone to die an excruciating death. The hospital behaved horribly, too, and I think those administrators and doctors who covered this up should also go to jail. The whole thing's a mess, but the nurse earned the jail time and license revocation. No way would you want her taking care of your family members, I'm sure.
I am certain there are multiple that have been swept under the rug.
@@chocolatethunder192 yes, she made multiple mistakes, as an ICU RN, I am very concerned over giving "whatever" & leaving, even she was told to leave by MRI staff. She was not assigned to the this patient, she was "floating" & had an orient with her. Typically, very few things can safely go inside MRI bay room, med scanner is not one of them, it will get pulled into the MRI & the whole things will have to be shut down for very long time... The only time to scan patient's bracelet is prior to the start of the procedure, in the hall. Regardless, this facility did not even had the scanners there in MRI. But big fat letters on the cap & label should have been a warning. I am not justifying her actions, but I thing she should not be THE ONLY ONE paying for the system failure, lack of check points in the process, not to mentions the whole hospital cover up, including multiple medical professionals, doctors & administrators. As it stands right now, she is being made an example & a scape goat.
The suffering the *real* victim went through, slowly dying in that manner, is horrific.
It only takes a second or two to double-check that you have the correct medication. She was grossly negligent in what she did. My mom was a head nurse for twenty years, so I am familiar with proper procedures. She should have read the vial out loud to herself, and again when telling the patient what its name is and what it's for.
As a nurse and as many of the nurses in the comments have said, the precedent being set here is dangerous. I fully agree she should’ve lost her license and was negligent. Nurses are human-imperfect people working in a very imperfect system. The responsibility cannot lie solely with the nurse when there were clearly multiple system failures that contributed to the mistake. Mistakes are inevitable and it’s true that the stakes in a healthcare environment are much higher. That’s why we have channels for reporting errors that are supposed to lead to a proper investigation, identification of the causes, and putting new systems in place to prevent them. Here there’s a nurse who reported herself and tried to go through those channels. Where is the responsibility of the hospital system being addressed? How did this get swept under the rug? Those are the questions of consequence here. Now more than ever, hospitals are pushing nurses to work in unsafe conditions with unsafe staffing ratios yet we’re still held to the same unrealistic standard that mistakes are not acceptable.
I read a lot of comments. I’m not in the medical field, but I am convinced this was a case of gross negligence!! Plain and simple.
This is an excellent example of why you DOUBLE CHECK every drug you are administering. DO NOT rely on vial cap color, on abbreviations, on the right thing being stocked in the correct pocket of the pyxis or the omnicell, etc.. ALWAYS CHECK. Since the nurses were required to override the system check, that means they should have been on high alert and even more vigilant than usual. There is always human error in these systems but READING THE VIAL to identify and confirm the drug and concentration takes ONE TO TWO SECONDS MAX and is bare minimum for safety. ugh this is just so so bad I feel horrible for the patient.
Your comment is textbook sanctimonious. Disregarding the realities of a tired mind that doesn’t think any longer to do all those basic required checks.
Brilliant analysis Dr. Grande! Thank you for sharing your thoughts on this particular case!
What a horribly tragic and needless death of a particularly vulnerable patient! Disgusting that some think the medical community should be immune from criminal investigations and charges. Disgraceful that the hospital tried to cover up this criminally negligent death!
Professional organizations always want to police themselves. And when they mess up. In their mind the ultimate punishment that could ever be handed down is the loss of a license. When you're in the business of holding other people lives in your hand. The ultimate punishment should be criminal prosecution. How many times have you heard police departments repeat the narrative. Just need more or better training? Every incompetent action is blamed on training or procedure. Not personal responsibility.
I agree. If i mess up at my job, i will get prosecuted and rightfully so. If you're handling peoples lifes, the worst thing that could happen is death, not a career change.
@@inkompetenzkompensationsko4188 I totally agree I'm in that position also. If I mess up or if I cover up. I can be criminally prosecuted federally.
I said the exact same thing.
They don't do it that way, because over 100,000 patients are killed EVERY YEAR due to medical mistakes, they wouldn't have any staff left if they held people properly accountable.
@@SoManyRandomRamblings I question that statistic.
I am a registered nurse, and while it's inevitable to make some medication errors during a career, this particular set of events is horrifying. most people outside of the hospital don't know that the number of medication errors nurses CATCH on doctors' orders is astonishing, and no one is talking about this. we find an error, call the doctor, and give him/her the opportunity to self correct. the nursing board should have taken away her license from the start, but criminal charges?? if we go down this rabbit hole, nurses may not self report medication errors, which makes everyone much less safe.
There’s a lot of people who haven’t worked in a hospital in here and it shows. There are some major systemic problems that contributed to this error that are completely being ignored in favor for blaming one person. Why was this med in the same machine that served the PET? It’s not exactly a med that is administered often there and it should not have even been there. Why was there no second nurse override? Most hospitals have a two nurse override and no permissions for a nurse to blind open a full drawer. Why isn’t the hospital system being held responsible for their part of the coverup, which the nurse didn’t actually participate in. Why wasn’t the patient monitored? Was it a drop off or was a tech supposed to have been there as well, what were the protocols and how were they not followed. Did she not scan because she chose not to or because she wasn’t able to? (I am actually not sure about this answer.) Yes. She made a med error. She made the steps that created the situation. However, that’s ignoring the fact that she should not have been able to make many of those mistakes.
I have been an RN for 40 years. Mistakes are going to be made in a hospital setting every day. Some are small, some are extreme. If anyone in healthcare believes they are impervious to making a mistake, they are dangerous. Nurses and doctors are HUMANS who want to help others in a setting that is always stressful, always changing, always complicated, always understaffed, always physically and mentally demanding. Ms Vaught had no intention of inflicting harm. To prosecute her as criminal is horrendously unfair. If placing blame and responsibility on the bottom of the medical community food chain is what society chooses, I would advise no one to go into nursing. So who will take care of you when you need a nurse?
So well said
🙏🌿♥️
I'm in the nursing field and I was just made aware of this case a couple of weeks ago... but, yeah, trading versed for vecuronium is a sentinel event: one which results in grievous harm or death due to neglect of safety protocols, it's sobering, but we exercise the 5 rights of med administration for a reason (right patient, right medication, right dose, right route, right time)... adhering to these would've prevented this...
People are saying this is a balanced analysis. It is not. Dr. Grande fails to mention the numerous systemic errors: the nurses being instructed to override the system; RaDonda being told it was okay to leave the patient; the fact that this was not Radonda's patient; the fact that a scanner was not available, to name a few. However, I still feel she was criminally negligent for NEVER checking the vial to make sure she was giving the right medication. Even so, I wanted to point out that this is NOT a balanced analysis.
I also agree with others that the hospital needs to be held responsible at the very least for trying to cover up the incident.
It's unfortunate but doctors/hospitals often bury their mistakes. We put healthcare professionals on such a high pedestal that we often have blinders on and don't do our due diligence researching doctors, surgeons, hospitals...If this patient had no family this likely would have been brushed under the rug. I do have respect for healthcare workers and doctors and realize they can often save lives and help improve our quality of life. However they are human, make mistakes, can be impacted by stress and some are more skilled than others.
Exactly, this!!! Over 100,000 patients die EVERY YEAR due to medical mistakes.
I watched a lot of this trial. The nursing expert was fabulous. She had almost 5-0 years experience. She list 15-20 separate acts that had to occur for the mistake to happen. As a recent surgical patient, listening to the circumstances of the case were terrifying.
It really makes me a bit afraid to go to a Hospital anymore.
There's a saying that my dad used to use when speaking of doctors: he would say "not all doctors were "A" students in med school". He was, of course, pointing out the incompetence of some in that profession. I believe it applies here also.
So true. Over 100,000 patients die EVERY YEAR due to medical mistakes, your dad was spot on.
Yeah. It seems to me she was generally a terrible nurse. I’ve even wondered if she’s just not very bright, or if she were on drugs, or if she’s ADD and can’t focus … nothing, however, nothing excuses her behavior. Unpardonable and reckless.
True.
When one goes to see a Doctor (even a Nurse Practitioner) that Patient doesn't know if that Doctor or NP graduated at the top of their Class or at the bottom.
They are like the Shadetree Mechanics of old - there are some good ones, some bad ones and the rest are mediocre.........
I really think you need to review some of the details of this case