As a retired Deputy sheriff, this sounds like a civil matter, more than a criminal matter. The question is who is bringing up the charges. I would bet that the hospital is behind pushing for a criminal charges. That would likely save them from civil penalty. I wish her luck. Most of us on the front lines of public health and safety get throne under the bus if it is to save the administration. Z Dog you sir have a great day.
Roy_Thousand in the case of healthcare workers who are trained to keep people alive and who have many more opportunities to be responsible for death (and are), an error is not always a “crime”. Yes negligence and maybe other categories depending on institution and state law. Yes - you operate at your fullest potential and keep up with what’s important to keep your patients alive but prosecuting every healthcare worker? People would work in fear, report less, and do more things that in the end harm patients....
@Roy_Thousand not under medical law. Look up respondant Superior. It's passes legal and ethical standards of care and responsibilities of the ones doing the hiring. She will be freed and sue them big time! She's got a great case.
I read the CMS report in its entirety, and it's a laundry list of systems errors. Yes, the nurse has a professional responsibility re: med admin practices, which seems like it was investigated by her state BoN. But the hospital was just *drowning* in inadequate systems and *utterly insufficient* institutional response. She is absolutely being hung out to dry as a scape goat.
@@randomdoctor8279 as I mentioned, she does have professional responsibility, to complete the 5 rights of med administration, and that's on her. It's true, this wouldn't have happened if she'd done that. But, as Z mentioned, humans are fallible and that's why we need systems to help us keep people safe. The ability to override and grab something like vec, the hospital's lack of scanners in radiology for scanning pt and med, the inability to visualize pts waiting for uptake before their scans, and the hospital's terrible response to all of this all contributed to a system where this could absolutely happen again. There full report is worth reading, because it highlights that, in addition to the obvious human error, the institution basically created an environment ripe for this type of error to happen.
CEOs make calculated cold-blooded decisions to increase patient to nurse ratios, patient to doctor ratios, mandatory utilization of higher & higher numbers of nurse practitioners supervised by fewer numbers of doctors. The administration’s at many facilities singular goal is to increase the speed of the patient conveyor belts from the second they hit the ER. Caring for patients is viewed as nothing more than the processing of widgets. And people are surprised the administration threw this reputable nurse under the bus???!!! Administrations seek their financial goals while putting all the responsibility on the “providers”. Welcome to healthcare 2019. This scenario could have happened anywhere in the U.S.. I’m a hospitalist & I am sickened.
they need to pass laws about patient ratio/safety. Nurses are overworked and management keeps piling more responsibilities on nurses to keep costs down.
No that is a really bad idea. The ANA doesnt even support this. Here is the rationale, when you have a law that said a nurse should have X amnt of patients, it automatically throws out all of the factors that are needed to do staffing such as acuity, nurse's skill sets/abilities, etc. These things are extremely important to take into consideration when doing staffing if there is a law that said 3 patients per nurse, it will create unsafe and inappropriate staffing because the highest priority will be the patient to nurse ratio and everything else is secondary.
I agree. We also need nursing unions that make sure our nurse/ pt ratios are low. I have had as many as 31 patients. You can't practice anything other than drive-by nursing with that kind of patient load.
Any death is a tragic event, but this type of legal behavior will just further dissuade more well-intentioned people from entering or being a part of healthcare when we’re already in a healthcare provider deficit.
Exactly. I'm a medical student and am already regretting my decision to have started this path. All this suffering and sacrifice only to be thrown in prison. Better to make the world a better place and help other through flipping burgers instead.
I am in radiology and currently transitioning out of healthcare. I am back in school for cyber security. I love doing CT but it also isn't worth the crap that we and nurses deal with. I have indirectly hurt a patient by hitting her leg and she got a cut (she was 94) and bled. I've seen nurses that needed to get their licenses revoked but nothing ever happened(it got covered up). Good nurses have shit happen to them that shouldn't.
The fact that Vanderbilt lied to the Medical Examiners office about the circumstances surrounding her death tells me everything I need to know about the culture of transparency and openness for process improvement.
Just a label hospital administration throws out there to say they comply with some regulation. When the sh*t hits the fan, they protect themselves by any means necessary.
I had to retire from nursing as I have MND. I see mistakes being made daily and noone caring. It's sad when the people who work over their hours unpaid over years are arrested when she could have been exhausted. She was doing what she believed was right. This lady might have died regardless and I would believe she deserves a level of repeat education to enable her to not make an error but she will never nurse again and in reality that must be pretty horrendous. I know losing my career has left me broken, how much worse will she be left feeling for an error. In any hospital facility there is a level of human error. It is incredibly sad for the family but they do seem to understand that their relative was very ill and needed to be in hospital. She sadly could have died from the bleed as much as human error.
ANY “nurse” who claims they haven’t had an “Oh my God” moment is either a liar or NOT a nurse. The panic fades only after one realizes that they didn’t mess up. Shame on those who are being judgmental, especially if they’re licensed healthcare professionals. But for the grace of God...
1 1000% agree with you( even 3 years later); especially in the Covid-19 times where healthcare workers are being forced to cut corners!!! I pray that we nurses all over the world have a little bit more sympathy for her!!! If you haven’t worked in the medical field; it’s too EASY to place judgement. She made a mistake & owned up to it; under normal circumstances; there’s consequences but not to the extend that this case has proceeded to. There’s also political propaganda in the mix🥴🥴🥴🥴
This case makes me scared to stay in nursing. It could have happened to anyone and companies will just throw you under the bus faster than you can blink
I’m an ICU nurse... the biggest mistake here isn’t actually administering vecuronium in error (though that’s clearly an inexcusable error). Rather, it’s the fact that the patient was left unmonitored during the scan. And that isn’t entirely the nurse’s fault either. This was probably an MRI scan, and you patients can’t have anything metal on them including most normal monitoring wires). No A-line transducers or normal O2 sat probes (which would have almost immediately notified the nurse that the patient was paralyzed and couldn’t breathe). Unfortunately, even though there IS a wireless MRI compatible O2 sat monitoring system that has been commercially developed, it wasn’t available in this instance. I think it’s dangerous to place ANY patient into a metal tube for up to 45 minutes on minimal monitoring when there are alternatives available
Jenna Khivka Pratt yes you can. I’m a mri tech at a level 2 trauma center. We do it all the time. We actually do anesthesia cases in our scanner. Which I don’t believe is rare. We monitor o2 sats on most of our patients. As techs we are trained on appropriate sat levels. If I believe a patient is inappropriate for our scanner, I am comfortable speaking up. As for this case it is my understanding that the patient never made it to the scanner. The patient was given the medication in holding and was not monitored. That the tech discovered the patient when they went to get her. I’ve seen many versions of the story, so I’m not sure which is correct. But, I cannot believe, in a hospital system as prominent as a Vanderbilt is, that their mri unit would not have mri safe monitoring equipment.
You have a good point. I have been thinking the whole time, okay, she gave vec, and what else?? There is so much more to this horrific tragedy than just one simple error. I wish the general public could understand that. So many people are so confident and happy to point fingers. It’s sad. And frustrating.
I completely agree, Z. This nurse is being thrown under the bus. As nurses we (literally) break our backs & work under high levels of stress w/ unsafe patient loads & our own hospitals won’t even have our backs. What happened at Vanderbilt wasn’t caused by ONE human; this was a multi-system failure we are talking about. My prayers are with this nurse as well as the sweet lady who lost her life as a result of this. No one becomes a nurse to do harm. ❤️ thanks for this video!
How many patients was she responsible for at the time. One! And only one. She killed someone. Because she skipped basics. Would Z or you think differently if it was a dirty old truck driver, that had to just plowed into a pedestrian? Or a contractor that skips adding the extra bolts because it is to hard to read the plans. Both the driver and contractor killed someone both are in prison how is a RN different? The buck stops with the last person to touch. The patient, the load, job site, my car, my kids room. Don't think I just have it out for medical I work full-time in it my little sis is a RT and the other 4 siblings are RN's or NP's with one in a nuro ICU. ( Thanks giving dinner conversations get vetoed by my non medical parents all the time for being gross) PS I think inprisment is the wrong answer for crimes most of the time! Including this one. Just my two cents worth
Oh please I’m a nurse I stop take a two second and double check, kind of sick of this it’s everyone else’s fault shit. She should lose her license, jail I don’t know.
Honestly, this is exactly why I’m trying to get out of bedside nursing ASAP after being a nurse for only a year and a half. There’s too much liability and we’re not compensated anywhere fairly for that. I could work an office job, make more money, and wouldn’t have to worry about losing my license and being thrown in jail. This woman, while highly highly highly negligent, not only lost her livelihood but also faces life-altering criminal charges. How is it that hospital administration makes more than we do with none of the liability, yet they were equally as liable?
As someone who works in the radiology department here at Vanderbilt I can assure you that we are more than replaceable. I does not help that we have a disastrous turn over rate and the people with years of dedicated experience sometimes don'thave a voice on how we can improve systems and protocol. At the end of the day everything is first looked at through the eye of will this cost the department money. In CT and fluoroscopy we always do a time out for any type of contrast or drug administered. The MRI techs should have also done this with the nurse. This is heart breaking because an individual who dedicated her life to serve others is now paying the price not just of her mistake but the sin pride and prestige of the VUMC.
Just Make It ....versed...should have never been ordered in the first place...second.... versed and Vecoronium..big difference.... horrific outcome.... everyone accountable from the doctor ordering it.... nurse not reading 5 rights.... pulling the wrong medication..questioning the order.... eye opener for all health providers
Yes, and without safety being a part of the culture then those who try and follow protocols are basically ridiculed and seen as a problem by staff and management.
Lizzy Tan Lizzy Tanny what you’re commenting makes zero fucking sense. Either you know nothing about this medications or you didn’t read the article or this is simply not your expertise. Goodbye!
Alejandro Zamora .... Wow...... idiot ...POS..... you want to battle come my way...... how old R....u fucken...Moran...... remember kid....karama come your way...... by the way I know my medication rights my dear.... versed vs Vecoronium...big freaking difference...... by the ways..you can keep freaking stupid comments to your staff...enough said
@@lizzytan277 nothing wrong with using versed for anxiety surrounding an MRI. Ativan is usually enough for most people, but if it takes a little versed it's better than full anesthesia IMO.
This terrifies me. I’ve had med errors before. So many meds to dispense, in such a short amount of time. Too many people with serious needs and not enough time to be everywhere at once. Passing meds while dealing with the guy with seizures and the guy bleeding out and the lady with dementia and the bells ringing and supervisors breathing down your neck. We’re expected to be superhuman and perfect all at the same time. It’s horrible what happened and I’m sure this nurse feels the guilt every day and will for the rest of her life. Jailing her is a terrible waste.
The nurse made a grossly negligent mistake but that is just what it is, a mistake. I can't wrap my brain around how she is being criminally charged for this without any evidence that she maliciously intended to harm that lady. She already has to live with the knowledge that she killed a patient. There's no justification for putting her in jail without holding everyone involved with that case accountable. I always tell my EMT and paramedic students "you will make mistakes, just strive to be as good as you can be to avoid the BIG mistakes"....
Jason Wolf It’s called criminally negligent homicide. She didn’t intend to kill the patient, but nevertheless, through her actions, the patient is still dead. It’s difficult for me to understand how anyone could mistake vecuronium for versed. And yes, I do have actual knowledge of this; I got licensed in ‘85 as a pharmacist, worked in hospitals for years, mostly in the critical care areas. I was on the code team and worked in the E.D., so, what I know didn’t come from a book.
@@sharonthompson7557 I scrolled down so many comments before I saw someone, like yourself, say the most sane thing. I can't wrap my head around how someone mistook Versad for vecuronium. They don't even look alike sound alike, even if you compare to its generic name (Midazolam). The other thing is this RN saw Versad was not loaded but saw vecuronium and said to herself that was the med?!? Finally, I agree with negligent homicide. She obviously did not do it intentionally (I hope). However this is a mistake that costs someone's life at the end. It's no different when you had a moment of lapse in judgment by running a stop sign at 2AM and killed someone. You might be the best driver in town but it doesn't matter. The mistake cost someone's life.
@@shannonlee2986 I read the report and did some more looking into negligent homicide and I see where they are getting the charges from. I had thought you had to be doing something illegal that caused a death such as DUI for it to constitute negligent homicide but a medical error such as this would qualify. Not sure why you felt the need to be an ass in your response but I'm not proud enough to not stand corrected when I misspeak.....
Or have it at a practice to scan the med and the ID bracelet... is that not a thing at Vandy? Just that step alone would have theoretically prevented this.
CEOs make calculated cold-blooded decisions to increase patient to nurse ratios, patient to doctor ratios, mandatory utilization of higher & higher numbers of nurse practitioners supervised by fewer numbers of doctors. The administrations at many facilities singular goal is to increase the speed of the patient conveyor belts from the second they hit the ER. Caring for patients is viewed as nothing more than the processing of widgets. And you are surprised the administration threw this reputable nurse under the bus???!!! Administrations seek their financial goals while putting all the responsibility on the “providers”. Welcome to healthcare 2019. This scenario could have happened anywhere in the U.S.. I’m a hospitalist & I am sickened.
As a nurse, I think this will only change when nurses and the nursing board stand behind a nurse accused of a crime the way doctors and the medical board stand behind a doctor accused of a crime. Doctors will typically rally around a doctor, but nurses will throw each other under the bus and "eat their young"
@@GinEric84 And if we feel that a mistake is not the same as murder than must mean we approve? Hop down from your high horse they buddy. Also this was an error, if you can't tell the difference between error and intent, have a look at en.wikipedia.org/wiki/Genene_Jones as a comparison.
This is so scary. Kinda makes me want to hang up my RN hat. I cannot even imagine what this poor woman is going through...I would be in therapy also for the immense guilt. Administration at its finest, I totally agree with you and I shared this for sure!!
So, you regularly ignore safety protocols and don't read labels before giving meds to patients? Cuz if so, please DO hang up your hat. We don't need negligent yahoos doing medicine.
Nieru yep, that’s exactly what I was saying....I give my patients whatever medication I feel like depending on the day without a care to safety and protocols....just wow.
@@LeeAnnMichelle04 well, I guess it's not the same thing, then, now is it? SMDH, God forbid nurses are expected to exercise a certain amount of caution and are held accountable for their negligence, right?
Nieru her negligence isn’t the issue. The issue is the criminal charges against her. There isn’t a nurse or doctor in this world that will honestly say they have never made a mistake in their career. Yes, this is the worst kind of mistake that can be made but there are other factors here. The nursing board did not revoke her license and she was not immediately fired or put on leave. Her firing and charges only came AFTER CMS threatened to withhold payment to Vanderbilt. If you know anything of state nursing boards then you know it can be pretty easy to get your license revoked or suspended. The fact that the TN BON did not do this is telling.
The reason the nurse goes to jail, is because somebody has to pay, and the nurse is at the bottom off the food chain without power so she's the logical sacrifice to get back to business as usual. It's about money, and protecting the elites, not the patients or front line workers.
As a nurse educator for 25 years, I love not only your videos of parodies, (which I use in class) but most importantly your advocating for nurses. I wish we had more multidisciplinary teams led by people like you.
Well said. I was caught in similar system failure that did not harm the patient, but lost my job of 12 years anyway. I can't imagine what this nurse must be going through. My heart goes out to her
I agree with you 100%, she has paid and will continue to pay for the rest of her life, she dont deserve this, accident will always happen but this is not the answer at all
Nurses adapt to poor staffing with short cuts which remain even when staffing is okay. Something has to give when you have too many things at the same time to do in reality, but all the management cares about is the charting and joint commission. It is dumb luck that horrible errors don't happen to more people.
As an ICU nurse 24 years what I can’t get out of my head is that she reconstituted a drug that she thought was Versed. Any seasoned nurse knows that Versed is not reconstituted. When she was required to reconstitute the drug that she had pulled that should have been a warning sign to stop. Also who pulls a drug and doesn’t look at the label? That being said a lot of the blame should be with the hospitals with their unsafe staffing ratios and their lack of institutional controls.
Just juxtapose cops and nurses for a sec. If a cop shoots someone to death by mistake thinking the suspect might be a threat, even in a non-threatening situation, the cop goes off scot-free most of the time. Now this nurse is being for charged for reckless homicide, for making a mistake. Both come from broken systems, one is allowed to go free, while the other is held accountable only to cover up the faults of the hospital. Absolutely disgusting and inhumane.
This is not "a mistake". This was a number of reckless and blatant errors on her part in violation of hospital policy and nursing standards of care... let alone common sense. If she had grabbed a similar look alike/sound alike drug, I could see "a mistake". But overriding warnings, ignoring a large PARALYZING AGENT on the RED CAP and reconstituting a medication that I don't even believe they make in an reconstitute (let alone routinely stock)... that's a special kind of stupid. That's EX-NURSE level of incompetence.
@@Critmedic Last time I checked, human error is a mistake. A nurse, who was out of her normal element/working environment mind you, tried to do right and help a patient feel more at ease during a scheduled procedure. Who knows what her patient load was that day? There so many unknown variables in regards to her mental state, from level stress to lack of sleep or even if she had time to eat something that day. No one saying that she was in the right or she didn't do anything wrong, all we are saying is that she shouldn't be the one taking all the blame for a failed system and a hospital that tried to cover it up. Would you jail every doctor who prescribed opioid in good faith, whose patients later die from taking them?
Leonid Sigal It isn't just a mistake. It was a CARELESS mistake. She didn't follow the safety protocol that needs to be implemented before any drug or treatment is given!
Leonid Sigal No. It wasn't just a mistake. It was failure to go through the proper safety steps. That is emphazised in nursing school! She refused to implement them. There were MULTIPLE failures to implement safety steps.
Thanks for being supportive...healthcare needs all catergories of caregivers working together...un fortunately there isn't any backup from management or administrators in hospitals for the caregivers..it's gone from bad to worse in the 30 yrs of being a RN..I'm so glad I'm retired now
Thank you so much for your support for nurses and other medical staff. I’ve been a nurse for almost 5 years and the worst part of the job for me is the verbal and emotional abuse from patients and their families, and occasionally doctors. I really appreciate you
Do you wan a culture where nurses cover up every mistake they make and the system never gets fixed? Because that's how you get a culture where nurses cover up every mistake they make and the system never gets fixed
I don't know what video you watched, but no where in this video does he imply or even state that mistakes should be covered up. I'm unsure if you're a troll or if you're actually serious in saying something like that, because its completely uncalled for and out of place for the point that is being made in this video.
@@justmeveginout8864 @This Video @John McClain no, you are all three very, very wrong. He stated 5 seconds later that what we need is radical transparency. You guys are the types of dudes to clip 5 seconds of a video and take words out of context to burn someone. It's literally disgusting. Now I ask, "WHAT VIDEO DID "YOU" WATCH."
@@metalhead4404 are you a nurse? Probably not. Medical errors are very common and the action by the legal team is unacceptable. Every single person in charge of the system etc. should be arrested too. The physician, pharmacist and the administration. You CANNOT blame the nurse for a system issue; remember, that starts at the top. Also, a system should never allow someone to override a NON-LIFE SUSTAINING medication. Once again, this is a system issue.
The fact that Vanderbilt hasn't changed their processes in over a year per CMS is a blatant sign that Vanderbilt Administrators should have been arrested instead!
This is getting absolutely crazy! I believe if they arrested her, they should hold everyone accountable, including pharmacists, administration, and doctors.This is crazy!
Why should the pharmacists be accountable? She overrode the pyxis, pulled the wrong med, RECONSTITUTED the wrong med while IGNORING the BRIGHT RED PARALYTIC LABEL, gave the wrong med with zero follow-up assessment. EVERY SINGLE one of these steps, if she did the right thing, would have prevented the death of this patient. Administration?? seriously?? Did they tell her to go and do a shitty job and kill a patient? I seriously doubt the doctors told her to do that. This is all her responsibility. She KILLED a patient with SLOPPY nursing practice in about the most horrific way possible, on Christmas Eve of all days!! She overrode the safeguards and REFUSED to abide by her training. At some point, "just" culture becomes "victim" culture and allows the sloppy and irresponsible to squirm out of accountability.
@@melissahahn4779 Not at that exact moment. I'm saying that the pharmacy policies such as better labeling may have prevented it. Or it may not, the point is that there is blame to be had everywhere.The nurse should be held accountable ,I just think arrested is too much.
I have been a nurse for almost 30 years. I have also read most of the replies to this video. First, reporting of medication error or medical errors in general are supposed to be used for quality improvement. Nurses etc. are not supposed to fear reporting an error. I find it funny, not really, that some people are damning this nurse for her error. Mind you, it was a doozy but she did not try to hide it. It was reported in good faith. She has probably suffered more since this happened by beating herself up by not following proper protocol, probably has suffered from guilt and depression since she realized what happened. But the bottom line is it happened, and we all have to learn from it. It is my understanding that she was floated to an area she was not entirely a costumed to. Her patient, whether going to CT or MRI should have been on a monitor to travel and should have been placed on a monitor in either radiology area she went to. It was not just her responsibility, there were others present.. You cannot tell me that a complete body scan would not have shown her not breathing with or without a monitor. The Radiology techs often talk to the patient during the scan, did no one ask this patient if she was ok during the scan, noting that she did not respond? A whole body scan for a subdural hematoma makes no sense. Why would they do that? The problem was in her brain... there are many questions I would ask. How much Versed was ordered? If she was unfamiliar with the area was she also unfamiliar with the critical care meds(versed is a critical care med), did she not know the generic name? For those of you that don’t, it is midazolam.... not even close to versed.... maybe the doctor should have known how it was written in the Pyxis ... maybe he should have ordered it that way.... if she was unfamiliar with Versed, maybe she didn’t know it didn’t get reconstituted.... she did not show malice.... if her defense needs an expert witness... they can contact any nurse educator that is not employed by Vanderbilt.... she should have had to go through training again to refresh her, but she should not be prosecuted
Any one of us could have made this mistake... I’ve been a nurse for 10 years and know that everyday things happen that could be avoided. I can’t imagine the pain and suffering this nurse is already going through! I would absolutely be beside myself if I made this error. You’re absolutely right... we need a system where we can honestly come forward with mistakes and problems... not prosecuted for them. We want to keep patients as safe as possible and not cover up the problems.
As an ex NICU nurse at REgions Hospital St Paul we were forced to take mandatory overtime. Even when expressing the inability to do a total of 16 hours with a 1-2lb infant and 5 + IVs going we were told it would be abandoning our duty and calls for firing! I put up with that for years! No parents ever knew. I’m sick for this nurse!
There was a nurse in Wisconsin Juile Thao That felony charges were brought against for overriding safety procedures. This was in 2007. It was found she worked a 16 hour shift, slept at the hospital, and worked again. More needs to come out about the kind of work environment is at Vanderbilt. I will be following this closely! The whole situation is scary! A quote from Diana Richardson RN from the Wisconsin Hospital Association stated "health professionals enter Healthcare knowing that a mistake could cost them their license, livelihood, and financial stability. What is incomprehensible is entering a career where a single error could lead to imprisonment" :-(
I totally agreed, Truck drivers are closely monitored for their sleeping patterns, that should also be the same for nurses. Also safety protocols no matter the fast placing.. They need systems to safety dispense meds to nurses after being signed by doctors, yes If a doctor gives a verbal order or Witten order, the machine needs its approval as well. That way the Doctor can be also accountable; and this would give the patient an EXTRA LAYER OF PROTECTION.
I am glad I am almost retired. Practicing medicine in America has become terrible. From administrators 'practicing medice', to corporate ownership stealing physicians compensation and now criminal charges for medical mistakes, the system is already ruined!
So who/whom are the parties pushing criminal charges? The patient's family doesn't want this, she has credible character witnesses and assuming her record is clean & clear I just don't see it. I'm pretty sure the District Attorney's office has more work than they need right now. So did they just "pick" this case out of the blue? I'm confused.
The District Attorney is looking for easy victims to increase his "cases tried" list. Nashville's DA is Glenn Funk, who has an interesting history in that he has prosecuted professional women on inflated charges numerous times. In February 2018, he forced the resignation of Nashville mayor Megan Barry over what he described as an "illegal" affair with a police officer. Then in August, HE was pulled over and issued a citation for speeding in a school zone DURING school hours. He's a real advocate for safety, that's for sure.
Tennessee does not need a willing victim to press charges. It *may* come in handy during abuse cases when the victim, with obvious injury, is too afraid of the abuser to speak out. BUT... I don't feel this case in the slightest is the way to use that rule.
@@shannonedna5241 Right! The criminal charge doesn't fit the situation. If this were to set a president then the healthcare and justice systems would both fall apart!
@@shannonedna5241 Apparently Tennessee doesn't need willing nurses either. Tennessee nurses consider moving out of Tennessee and memorize the name of this prosecutor when he shows up for treatment, REFUSE to treat him.
It makes me sad but I wish I could love this video a hundred times! THIS is exactly the type of administrative response that makes me very adamant, when training new nurses, about the importance of your own malpractice insurance. Your hospital may say they have insurance on you but when the chips are down, they will throw you under the bus to cover their own behind! Unfortunately that insurance doesn't protect from criminal charges but it will be the best $100/yr you spend. So so many things wrong with this whole situation. We clearly don't do this job for the money. It's a passion and a calling. Nurse/patient ratios, length of stay, little protection on the front line, long hours without breaks, lack of respect between departments and doctor and nurses, poor systems all play into the likelihood of these mistakes becoming more frequent. Our system is already broken and will only be more irrevocably damaged if they successfully convict her. #IStandWithRadondaVaught
What a joke. Every prospective doctor and nurse in the country needs to pay attention to this. Go through intense schooling, get into crazy amounts of debt, work yourself to death for the good of others, get thrown in jail when you make a mistake that there should be a litany of safeguards to prevent. Good luck kids, Telehealth here I come.
Medical student here. I am thinking about jumping out of medical training but am drowning in debt. I try my best... but if that best is gonna get me in prison (no one is perfect) then no thank you.
Safeguards... you mean like the medication dispensing cabinet that required a specific override to obtain that medication? Or the hospital policy requiring verification by another nurse? Or the hospital policy and nursing standard of care requiring you to monitor your patient for response to medication (especially as either intended and accidental medication are considered "high risk")? Or perhaps the safeguard of common sense that should clue you in that if you have to suddenly reconstitute a common medication that you NEVER had to reconstitute before so perhaps one should double check that that is indeed the right medication? Or perhaps the safeguard of the RED CAP with "PARALYZING AGENT" written on it in large, capital letters in contrasting color? But you're right. More safeguards. Apparently, you can't rely on the concept of a trained nurse with a functioning brain.
@@sharonthompson7557 and CritMedic, Nurse here-I agree with you about the egregiousness of the errors made by the nurse. However, I don't think criminal charges are the answer. Loss of license and civil penalties, sure. Jail? No. JMO.
@@shawnreed7876 I know a friend who was an LPN and after multiple problems she gave it up for a union school custodial job. Made more money & just retired. Too many jealous female nurses who delight at throwing others under the bus.
Retail pharmacist here. A few years ago I grabbed a box of duoneb thinking it was budesonide and overrode it to save time. Turns out the patient had a non-severe allergic reaction to the albuterol and chose to visit the doctor, discovering the error. The patient returned and notified me of the error and I was mortified. It brought tears to my eyes. Fortunately, she was one of the kindest patients I’ve ever had and she insisted that I not hold it against myself. The morals here IMO are 1) we all make mistakes. Sometimes they are minor, sometimes serious. The factors that determine the seriousness are often beyond our control. 2) Always express remorse and apologize sincerely. Most reasonable people simply want an apology and do not want to destroy your life 3) learn from your mistakes. When similar scenarios present again, remember those past patients to help you avoid the same errors.
Her arrest will have an unintended consequence of worsening quality by hiding medical errors as opposed to trying to solve the multiple system errors which are typically the problem.
Zdogg, you make so much sense about healthcare priorities and the atrocities of healthcare today. I listened to your “burnout” video and it woke me up to how I have been feeling lately. I left healthcare for the very reasons you mentioned. Thank you for being a voice of reason.
This RN is with you 100%! This never should have happened, but I totally understand how it did. The fact that a patient receiving even the slightest sedation for an MRI was not being monitored is mind boggling and terrifying. My heart goes out to that nurse.
Disagree. It is the sheer LAUNDRY LIST of errors that she made that makes HER accountable. If she had used her nursing training AT ANY POINT in this sequence this woman would still be alive. 1: overrode the Pyxis 2: pulled wrong med from Pyxis 3: reconstituted a drug and ignored THE BRIGHT RED LABEL THAT SAYS PARALYTIC!!! 4: versed does NOT have to reconstituted!! 5: administered said wrong drug and walked out without assessment!! If she had stayed 2 mins that would have been enough to know the patient was crashing! This scenario tells me she had ZERO clue about the drug she was supposed to be giving and didn’t bother to take the time to look it up or, HELL, call the PHARMACY!! Who the hell gives an IV push sedative and just walks out and leaves the patient??? Here we don’t give Versed outside of conscious sedation which means continuous monitoring. So...Using your argument... we should not punish accidental deaths because there was no intent to harm. Should we not punish drunk drivers when they kill someone?? What about people that accidentally hit and kill pedestrians?? I don't hear any calls not to punish these people because everyone knows that the deaths are mostly preventable when vehicles are operated as trained and in a responsible manner. The same applies to this scenario...this was preventable and because she acted in a way that was contrary to training and irresponsible someone died. This was not just ONE med error...it was a series of tragic F-ups!!! Quite frankly - you are all giving her a pass because you are superimposing yourselves into this situation... you don't want her charged because, in your own minds, you are covering your own asses. Quite frankly it's disgusting and you all should be ashamed. You all want to talk about precedent?? What kind of precedent does this set if she is just allowed to go?? It tells our patients that their lives are not as important as our individual freedom and that when it comes to errors, we would rather stick together than stick up for them. It tells future nurses that it's no big deal to make dangerous mistakes because they will just get bailed out by their fellow nurses because we got each other's back. Not this nurse.
That’s insane!! Heart goes out to the nurse and the family! I’ve made a mistake or 2. There shouldn’t be a way to override without a second pair of eyes. The national shortages alone should make it clear that we need the system and the processes to have our backs. We are humans!🤦🏾♀️
at Ohio's Hospice of Dayton (4th palliative IPU in the nation), they DEFINATELY have charge RN the only one who can pull override drugs! And is 2 RN witness...
Maybe we should start refusing to provide care if they make these impossible conditions. Then the whole system will break because it’s like that everywhere.
While no one can cast ANY stones at this nurse, I must, MUST say that when you look up a med and it doesn’t pop up, overriding the system was not the next logical step. When I’m trying to put in an order or grab a med, if I can’t find a mess under the commercial name, I take the one second and google that med. it usually gives you that name you looked up, the generic name ( which may be what you need to get the right med) and several other names it COULD be. The other errors were, yes, a result from a faulty system and overworked and rushed, but what I don’t understand is why she didn’t check for the generic name of versed.. even if she’s on older nurse...there’s a drug book in the med room, most likely... or go ask someone! “ hey I’m trying to pull this med and it isn’t coming up. Can you help me?” I believe this one not-checking-generic-names things was the downfall. I’m a fairly new nurse and I know I have years and years to learn, but even now, if I don’t know something or something doesn’t look or feel right, I look it up, or ask someone else until I have the appropriate treatment for the patient...I too am very overworked and underpaid and my plate is too full also....but Im still gonna make sure I’m doing the right thing. Please learn your generics WITH your name brand drugs!
In my view as a nurse I have the fullest respect for the pyxis machine and all the medications in there from the first day I was rrained and ongoing I bring my computer on wheels and verify the medication per the mar. I respect all nurses and the feeling this nurse is going through I pray over her and all medical staff. What we do is not easy and at times it is down right nerve racking but God gave us these to hands to nurture heal and hold. Be blessed my fellow nurses.
I agree 100%, ZDogg. It's ashame; another case of administration throwing staff under the bus. Despite my thoughts on the errors that occurred, I think it's absurd for her to have been arrested. No grounds for a criminal case, and just torturous to the poor nurse.
The more I read the more upset I get... The nurse was hired for an ICU in Oct 2015, she received her license in February 2015! How in the hell did she have enough experience to be an ICU nurse? Fast forward about 2 years and something bad happens... I looked at the job posting for a neuro ICU nurse and found that they only require 6 months experience, so I guess she had that... it also mentions that the unit has "charge nurse help all" so does that mean she was a charge nurse? After this happened, Vandy did not report this sentinel event (required by law), hid it from the ME, settled out of court with the family (with a NDA) and fired the nurse. The hospital only took action (other than paying off the family and firing the nurse) after there was an anonymous complaint filed with CMS and the investigation from CMS found that they were in violation and if they did not fix it they would lose CMS $. That got their attention, so they revised some policies, changed what meds can be removed with an override, and outlined a plan to train nursing. And it only took them just under a year to fix their flawed system that set up the conditions that allowed the nurse to make her error. So the hospital hid evidence, failed to report, and only changed the system when they were called out, by CMS, with the threat of lost income... but the nurse is the one being charged with a crime. What about the administrators? No charges for falsifying records? Failure of their duty to report? Attempting to cover up the incident? No? Why not? Because a nurse who makes about 50-70k/year is a much easier target to go after than a hospital admin who probably makes > 150K/year and gets bonuses = to a years pay for a nurse. Now I see that she has lost her license, and is being fined $3000 and is responsible for "costs" of up to $60,000... plus she has to pay her counsel, and still has the trial to go. And people wonder why there is a nursing shortage... @ZDoggMD how about an update video? Job posting: vanderbilt.taleo.net/careersection/.vu_cs/jobdetail.ftl?job=2000144&tz=GMT-05%3A00&tzname=America%2FChicago Board of Nursing order: apps.health.tn.gov/Licensure/DisplayPdf.aspx?profCode=1703&LicenseNum=205702&ActionDate=7/23/2021
I am sorry for all my fellow nurse practitioners, nurses, PAs, and MDs. A culture that criminalizes mistakes will hide those mistakes. We should learn from those and continue to find the root cause of these. A common goal of safety and shared knowledge is needed to prevent future mistakes. I am profoundly saddened by this news.
As a nurse, we are encouraged to report all errors, including potential/near miss type errors (i.e. Wrong drug in a Pyxis pocket, etc). I have reported on MYSELF before, as we're taught, to monitor and implement changes to improve PATIENT safety, without fear of retaliation. This kind of stuff, the firing of the nurse, then criminally charging the nurse (hello? Intent?) looks an awful lot like retaliation. This is what prevents reporting, increases fear and covering up incidents, leading to continued patient harm.
(20+Year RN here) agree with you Dr. z Thank You for being this situation to light.. so many mixed emotions, my heart hurts for everyone involved! Making mistakes as a nurse stays with us forever .. prayers and 100% support for you Rosanna (so sorry if I misspelled your name)
I missed a sepsis in an 11 month old child. It was one of those nights, waiting room out the door, patients lining EVERY hallway, some in chairs, most on a stretcher. I told the nurse to send in labs. The kid looked ok, but sleepy. I gave them explicit instructions to bring this kid back if ANYTHING looks different or worse. Lucky for me and the kid, the parents brought them back, with spots and a 104 temp. This happened while I was off duty, but the phone was ringing, and my supervisor told me what was going on. He thanked me for doing good patient returns if changed, and it was the worst week of my life. The patient got airlifted to San Francisco General and from there I lost track. I worked nights for 15 years, in the ER, seeing as many patients as was possible. Prompt Care for 6 hours and then Trauma for the other 6 hours. Nurses are the glue that holds this system together. If you start arresting them for working their asses off and making an error, everything will come crashing down. In defense of this nurse, a paralytic should not be in with the usual drugs. There has to be a way to separate them. I’m a PA so I did not have access to the drugs, I already had more then I could do anyway.
No i do not feel she should go to prison for what happened .. It was not done on purpose .. This is so sad i will pray for her she desrves better then what is happening to her
Work for a similar university medical system and our CNO has told us that safety reports cannot be discussed because they are a private matter. I have brought up that what I was taught in nursing school was that the purpose of these reports is to investigate areas that need improvement and how is our unit supposed to improve if changes are not made and mistakes are not discussed among the team to avoid them in the future.... crickets....
I love that you can publicly lay out the “system errors”, identify professional errors, and their attempt to charge one administrator. Errors are made in “practice”, normally without intent, hence, a mistake. As health professionals, “we” understand the holes in the process that continue to plague our ability to provide safe care. Nurses already are stretched thin, there is a national shortage, and rumors hold that “we eat our own”. The system will quickly deteriorate if we instill yet another reason why nurses will fall away from the profession.
I am in complete agreement with you on this 10,000%. I am an FNP with an extensive background in critical care. The self righteous police state which arrested her and the administrators above her should then share that prison cell. Shameful. No matter how Vanderbilt "handles" it, this one act alone negates any "good" thing they do. Filthy. Disgusting. Black mark on Vanderbilt.
Throwing this woman under the bus will not fix the system or the problem. Fix the problem. Make it impossible to put a sedated patient in an unmonitored bed. Make it impossible to pull a paralytic by accident. Throwing her under the bus only allows more accidents and problems . Prosecution of her fixes nothing and allows a broken system to continue “ as is”. Make this accident impossible to happen again and you will save lives. This woman is being prosecuted because she is human . Humans are not supposed to be perfect. They can’t be. The administration is paid big bucks to create a system the leads to safer care. Clearly they have not done so.
A dog wouldn't work under such punishment. Paralysis of decision making and fear of punishment degrades the ability to provide proper care. The institution is sacrificing her to deflect attention from their flaws, and nothing will change.
I agree, this was not a deliberate homicide or reckless abuse. The systems for safety; the Pyxis and on-going procedural assessment, weren't in place. Sure nurse Vaught is partly at fault, but this was a mistake, not a murder in cold blood.
I couldn’t agree with you all as well. This was a systems error resulting in a terrible incident resulting in at least two victims, more when you count family and friends, and now what does Vanderbilt do, compound the situation and make another systems error; in addition, I think they’ve made a moral mistake, sent and sent a terrible message to all of their staff indicating that what little they did care for them was conditional, all mistakes maybe punitive. They clearly learned nothing rom he event. I think this will add to staff suicides. Doctor’s, nurses, RT’s, CNA’s, and techs give their heart and souls to their patients and the general public has no idea what we really do and what we are legally responsible for. Zdogg MD you saved me though,! I was going to attend Vanderbilt for APN school, I am glad I am not going to! My prayers go to the family affected and this hard working nurse who made a human mistake!
I completely agree. Coming from someone who has had a family member ACTUALLY murdered for real. So sad for both parties. So pathetic for the whole system she worked for.
It is so disheartening that nurses do not really behind our own. We should be in the streets with signs and bullhorns behind this. The conditions and stress this RN was under led to this mistake happening. We as nurses need to fully educate the public on the realities of healthcare....the constant understaffing, increased patient load, increased charting requirements, pressure to "make the patient happy at all costs" even if its contrary and detrimental to the patients BEST interest. Not even counting the system failures incorporated in this. My heart goes out to this nurse. And I agree this is ridiculous, scapegoating and gaslighting personified.
Preach it Z!!! What really needs to happen for a true overhaul if the system is for Medicare and Medicaid to pull funding/ payment for any hospital that cannot adequately prove and show ongoing record of administration/ leadership, as you put it, enacting and monitoring good medical practices that are GOOD FOR THE PATIENT FIRST and not for profit margins. Any hospital that puts profits before it care should be shut down. Sadly, that would probably be most if not all in the US. What a complete tragedy on all fronts!!
We're gonna end up with no medications being able to be overriden in pyxis/ Omni machines. Arrest / criminal charges will not help. It will make hospitals and health systems be less open about errors. Reminds me of the pharmacist in Ohio that made the error in chemotherapy for a pediatric patient.
I want every hospital administration to spend a day in the shoes of their nurses and see how they feel about the things they implement. After I became an RN and worked hospital I hated it! Maybe I'm not tough enough but I really struggled with being in a place where I was bullied, unappreciated, and expected to know everything as a new grad (left out to dry with 10 patients of my own). I stand with this nurse who obviously feels extreme pain and guilt and has been kicked to the curb because this hospital doesn't want to loose it's money. That's all the hospital cares about, they don't care about the patients or their employees, just $$$$$ that they make. It's disgusting how she's being treated for this.
I also know cases where doctors have caused great harm to patients ON PURPOSE and have just casually moved on from that hospital, not brought up on charges, and now own their own practice like nothing ever happened.
I agree with you completely based on the facts that are known/disclosed. Scapegoating this nurse by indicting her when she has already paid the high price of job termination and mental anguish is cruel. Furthermore, it points to a healthcare system that is unwilling to take an honest look at the multiple system and process failures at play in this tragedy. Whatever CAPA plan was submitted to CMS, it was likely superficial, especially considering how reluctant the institution is to release it to the public. If they truly addressed the root causes that led to this patient's death, why not be transparent and disclose it?
I support you too Radonda. It's unfortunate that so few people in leadership are actually leaders. She should only be in jail if she did it on purpose. Thanks for supporting us Z
My biggest complaint about incident reporting systems is they can be used against a person either vindictively by a fellow employee or by management even though the process is not supposed to involve punishment. The overall goal is correct but the process is flawed. They should make reporting systems anonymous, so it can’t be used punitively against the person(s) at fault if the overall goal is to correct flawed policies. Currently hospitals use the polices to deflect financial responsibility which they won’t get out of unless there is extreme gross negligence which will be reported by other methods anyways. It’s always about the money.
Incident reporting can't be trusted at all. It makes one constantly on the lookout toward their fellow co-worker & leaves a negative vibe that no one can be trusted. Worse environment to work in. When trust is gone, then safety becomes a greater concern. Any incident needs addressed at the team level.
Has the American Nurses Association stepped up to advocate for her? I recently retired after 42 yrs of nursing. I started each shift asking God to keep me from making an error that harmed someone, or worse. It is every nurses fear, and it’s only by the grace of God that I got through it. Nursing is the only profession I know of in which one is held responsible for the actions of those above us and below us as well as ourselves. I appreciate your support for this nurse. I never encourage anyone to choose that profession (neither do I discourage it). It’s not for cowards, that’s for sure!!! Making errors a criminal offense will not help the nursing shortage nor will it attract quality people to the profession. 😕
I'm completely agreeing with you. I'm a neuro RN and this scares me. How can they possibly put a caring nurse who made a grave error in prison?!? This is crazy
I tend to agree with ZDOGG on this one. The five rights of medication should just be a coaching and counseling session for her and the fact that she went on unmonitored in radiation speaks more about the protocols that are put in place that need to be re-valuated by administrators
Not by administrators, they are focused on money. healthcare needs to replace these administrators with clinicians who know nursing care as more than a cost.
I am a Nurse here in Nashville at a different hospital. We are following this story very closely. My first question when I hear blame of a nurse is; How many patients was this nurse caring for at the time? What was their acuity? How many other jobs was she doing? This is a problem across the country, there are no laws in place to protect the nurse or other healthcare providers from being greatly over tasked. We do the best we can do for our patients and continue to adapt. This will continue until a great tragedy gets national attention, or we stand up and force laws to change. I encourage all to look up safe nursing ratios and what bills are in senate to support them. Make the noise to get these bills approved 😊
This is tragic for everyone involved. Yes the nurse bypassed the system and made grave errors. But what happened to needing a co-signer when overriding these kinds of meds?? My thoughts: the nurse should be held accountable but not as a criminal. Maybe license suspended with extensive education and counseling, then be able to return to the bedside with a probationary period. The point is that it seems to have been a mistake but not malicious or purposeful. This has gotten to me down to my core. This also has me questioning whether I want to continue at the bedside. I am very careful and follow safety policies but we are still HUMAN. The direction healthcare is going...is it even worth it anymore? May God be with this family, nurse and all involved.
Omg you took all the words right out of my mouth. This story is haunting me, literally. To the point I wonder what I’m even doing anymore. Errors or not, do I really want to work in this system!?!
As a nurse myself this makes me absolutely terrified for a multitude of reasons. I absolutely agree with you about how this will make people cover up errors even more. I have so much stress every single day about going to work and making a mistake. The stress of being a nurse is REAL because of the fear instilled in us that things are our fault since we are the front line.
Actually, research shows that 12 hour shifts increase patient safety by reducing the number of staff handoffs in a 24hr period (2 handoffs vs 3) while still being a manageable shift. Anything beyond 12hr, like when nurses are asked to "work late" and cover a 16, I agree with you completely. But a 12 seems to be the sweet spot between not too long a shift and fewer staff handoffs.
I agree with you, Z! I support this nurse, she has suffered enough. I have been an OB nurse for 25 years now, and I understand the stress of tragic incidents. Each baby that is born with my name on its chart, I'm liable for 21 years!!!!! So sad for this nurse and her family.
modernization and automation should remove the room for human error. if a system allows room for a human to make mistake, then that system is broken. I think it is unfortunate that this event happened, but punishing the people involved in this accident would just be masking the symptoms. We should address the causes of this accident which, in my opinion, is systems being developed or influenced by people not working in the field it is deployed in. Should she be punished for her mistakes? If the family says no, then they should honor their wishes.
Sometimes, some of the onus is on the administrator of the drug to make sure they actually obtained the correct medication. Overriding technological safeguards and blatantly ignoring ANY of the writing printed on the vial... I found the cause of your accident -- a bad and incompetent nurse. One that broke hospital policy and nursing standards of care.
Yes we need the ability to override for emergencies. At that time the administration is in the hands of the person giving it. That is when you have to go back to your five rights and armband verification and when possible two nurse verification on a drug like that.
As a retired Deputy sheriff, this sounds like a civil matter, more than a criminal matter. The question is who is bringing up the charges. I would bet that the hospital is behind pushing for a criminal charges. That would likely save them from civil penalty.
I wish her luck.
Most of us on the front lines of public health and safety get throne under the bus if it is to save the administration.
Z Dog you sir have a great day.
Love your insight on this. Thanks!
That is so disturbing....money talks and I guess matters more than this woman’s life
Roy_Thousand in the case of healthcare workers who are trained to keep people alive and who have many more opportunities to be responsible for death (and are), an error is not always a “crime”. Yes negligence and maybe other categories depending on institution and state law. Yes - you operate at your fullest potential and keep up with what’s important to keep your patients alive but prosecuting every healthcare worker? People would work in fear, report less, and do more things that in the end harm patients....
She can and likely will sue and win.
@Roy_Thousand not under medical law. Look up respondant Superior. It's passes legal and ethical standards of care and responsibilities of the ones doing the hiring. She will be freed and sue them big time! She's got a great case.
I read the CMS report in its entirety, and it's a laundry list of systems errors. Yes, the nurse has a professional responsibility re: med admin practices, which seems like it was investigated by her state BoN. But the hospital was just *drowning* in inadequate systems and *utterly insufficient* institutional response. She is absolutely being hung out to dry as a scape goat.
Bre-anne Brown Wow!
Where's the system error of an unthinking nurse administering vecuronium by overriding the system and failing to perform mandated checks?
@@randomdoctor8279 as I mentioned, she does have professional responsibility, to complete the 5 rights of med administration, and that's on her. It's true, this wouldn't have happened if she'd done that. But, as Z mentioned, humans are fallible and that's why we need systems to help us keep people safe. The ability to override and grab something like vec, the hospital's lack of scanners in radiology for scanning pt and med, the inability to visualize pts waiting for uptake before their scans, and the hospital's terrible response to all of this all contributed to a system where this could absolutely happen again. There full report is worth reading, because it highlights that, in addition to the obvious human error, the institution basically created an environment ripe for this type of error to happen.
Bre-anne Brown ~ Bravo! 👍👏👏👍
Excellent comment and reply. I completely agree with you.
CEOs make calculated cold-blooded decisions to increase patient to nurse ratios, patient to doctor ratios, mandatory utilization of higher & higher numbers of nurse practitioners supervised by fewer numbers of doctors. The administration’s at many facilities singular goal is to increase the speed of the patient conveyor belts from the second they hit the ER. Caring for patients is viewed as nothing more than the processing of widgets. And people are surprised the administration threw this reputable nurse under the bus???!!! Administrations seek their financial goals while putting all the responsibility on the “providers”. Welcome to healthcare 2019. This scenario could have happened anywhere in the U.S.. I’m a hospitalist & I am sickened.
they need to pass laws about patient ratio/safety. Nurses are overworked and management keeps piling more responsibilities on nurses to keep costs down.
Across ALL of nursing....
YES!! I cannot agree more
No that is a really bad idea. The ANA doesnt even support this. Here is the rationale, when you have a law that said a nurse should have X amnt of patients, it automatically throws out all of the factors that are needed to do staffing such as acuity, nurse's skill sets/abilities, etc. These things are extremely important to take into consideration when doing staffing if there is a law that said 3 patients per nurse, it will create unsafe and inappropriate staffing because the highest priority will be the patient to nurse ratio and everything else is secondary.
Yes and its disgusting..
I agree. We also need nursing unions that make sure our nurse/ pt ratios are low. I have had as many as 31 patients. You can't practice anything other than drive-by nursing with that kind of patient load.
Any death is a tragic event, but this type of legal behavior will just further dissuade more well-intentioned people from entering or being a part of healthcare when we’re already in a healthcare provider deficit.
Exactly. I'm a medical student and am already regretting my decision to have started this path. All this suffering and sacrifice only to be thrown in prison. Better to make the world a better place and help other through flipping burgers instead.
Shawn Reed thank you for your sacrifice. Your patients will seldom appreciate it and never understand it.
I am in radiology and currently transitioning out of healthcare. I am back in school for cyber security. I love doing CT but it also isn't worth the crap that we and nurses deal with. I have indirectly hurt a patient by hitting her leg and she got a cut (she was 94) and bled.
I've seen nurses that needed to get their licenses revoked but nothing ever happened(it got covered up). Good nurses have shit happen to them that shouldn't.
Haha we meet again!!! Not Dr dray this time. I knew I kept seeing your comments
Good point. We need ethical and overall good moral people and we won’t get this if people feel threatened and scared to enter this type of work
The fact that Vanderbilt lied to the Medical Examiners office about the circumstances surrounding her death tells me everything I need to know about the culture of transparency and openness for process improvement.
Just a label hospital administration throws out there to say they comply with some regulation. When the sh*t hits the fan, they protect themselves by any means necessary.
She was probably terrified.
I had to retire from nursing as I have MND. I see mistakes being made daily and noone caring. It's sad when the people who work over their hours unpaid over years are arrested when she could have been exhausted. She was doing what she believed was right. This lady might have died regardless and I would believe she deserves a level of repeat education to enable her to not make an error but she will never nurse again and in reality that must be pretty horrendous. I know losing my career has left me broken, how much worse will she be left feeling for an error. In any hospital facility there is a level of human error. It is incredibly sad for the family but they do seem to understand that their relative was very ill and needed to be in hospital. She sadly could have died from the bleed as much as human error.
ANY “nurse” who claims they haven’t had an “Oh my God” moment is either a liar or NOT a nurse. The panic fades only after one realizes that they didn’t mess up. Shame on those who are being judgmental, especially if they’re licensed healthcare professionals. But for the grace of God...
1 1000% agree with you( even 3 years later); especially in the Covid-19 times where healthcare workers are being forced to cut corners!!! I pray that we nurses all over the world have a little bit more sympathy for her!!! If you haven’t worked in the medical field; it’s too EASY to place judgement. She made a mistake & owned up to it; under normal circumstances; there’s consequences but not to the extend that this case has proceeded to. There’s also political propaganda in the mix🥴🥴🥴🥴
Yes!!!
I am a cmt below lpn. I could have been this lady. I am glad that my oh sh%t was minor.
This case makes me scared to stay in nursing. It could have happened to anyone and companies will just throw you under the bus faster than you can blink
my thoughts as well, I'm in Australia but if she looses this it will spead
Shock, if you torture a patient to death the hospital won't defend you. Who would have thought?
It could definitely not happen to me because I am not a dangerous idiot
@@GinEric84 The irony of the typo you just made.
@@robbjr7879 that isn't a typo it's a Google voice error.
Thanks though, I fixed it
I’m an ICU nurse... the biggest mistake here isn’t actually administering vecuronium in error (though that’s clearly an inexcusable error). Rather, it’s the fact that the patient was left unmonitored during the scan. And that isn’t entirely the nurse’s fault either. This was probably an MRI scan, and you patients can’t have anything metal on them including most normal monitoring wires). No A-line transducers or normal O2 sat probes (which would have almost immediately notified the nurse that the patient was paralyzed and couldn’t breathe). Unfortunately, even though there IS a wireless MRI compatible O2 sat monitoring system that has been commercially developed, it wasn’t available in this instance. I think it’s dangerous to place ANY patient into a metal tube for up to 45 minutes on minimal monitoring when there are alternatives available
The question becomes how did she have access to vecuronium? This med should not have been available for her to dispense.
@@violethill4813 I honestly don't know how. I don't really know what it is, I'm guessing a drug that kills you or something, right?
Can you monitor end tidal co2 with a (very long) dual cannula in MRI?
Jenna Khivka Pratt yes you can. I’m a mri tech at a level 2 trauma center. We do it all the time. We actually do anesthesia cases in our scanner. Which I don’t believe is rare. We monitor o2 sats on most of our patients. As techs we are trained on appropriate sat levels. If I believe a patient is inappropriate for our scanner, I am comfortable speaking up.
As for this case it is my understanding that the patient never made it to the scanner. The patient was given the medication in holding and was not monitored. That the tech discovered the patient when they went to get her. I’ve seen many versions of the story, so I’m not sure which is correct. But, I cannot believe, in a hospital system as prominent as a Vanderbilt is, that their mri unit would not have mri safe monitoring equipment.
You have a good point. I have been thinking the whole time, okay, she gave vec, and what else?? There is so much more to this horrific tragedy than just one simple error. I wish the general public could understand that. So many people are so confident and happy to point fingers. It’s sad. And frustrating.
I completely agree, Z. This nurse is being thrown under the bus. As nurses we (literally) break our backs & work under high levels of stress w/ unsafe patient loads & our own hospitals won’t even have our backs. What happened at Vanderbilt wasn’t caused by ONE human; this was a multi-system failure we are talking about. My prayers are with this nurse as well as the sweet lady who lost her life as a result of this. No one becomes a nurse to do harm. ❤️ thanks for this video!
How many patients was she responsible for at the time. One! And only one. She killed someone. Because she skipped basics.
Would Z or you think differently if it was a dirty old truck driver, that had to just plowed into a pedestrian? Or a contractor that skips adding the extra bolts because it is to hard to read the plans. Both the driver and contractor killed someone both are in prison how is a RN different? The buck stops with the last person to touch. The patient, the load, job site, my car, my kids room. Don't think I just have it out for medical I work full-time in it my little sis is a RT and the other 4 siblings are RN's or NP's with one in a nuro ICU. ( Thanks giving dinner conversations get vetoed by my non medical parents all the time for being gross)
PS I think inprisment is the wrong answer for crimes most of the time! Including this one.
Just my two cents worth
Never Sleight i do understand & appreciate your POV! Thanks for this input😊
Oh please I’m a nurse I stop take a two second and double check, kind of sick of this it’s everyone else’s fault shit. She should lose her license, jail I don’t know.
Thank you for your support. This is the only place we get it. Nurse out.
Judy Kel amen! It’s so nice to hear a doctor actually appreciate us and be willing to call out the bs
Honestly, this is exactly why I’m trying to get out of bedside nursing ASAP after being a nurse for only a year and a half. There’s too much liability and we’re not compensated anywhere fairly for that. I could work an office job, make more money, and wouldn’t have to worry about losing my license and being thrown in jail. This woman, while highly highly highly negligent, not only lost her livelihood but also faces life-altering criminal charges. How is it that hospital administration makes more than we do with none of the liability, yet they were equally as liable?
Yes i agree i recently left a job one nurse to 40 Dementia/ Alzheimer patients. Maybe one or two CNA.
What office job pays more than nursing bedside in a hospital? Sign me up!
@@dorindas7330 guessing case management or outpatient setting
As someone who works in the radiology department here at Vanderbilt I can assure you that we are more than replaceable. I does not help that we have a disastrous turn over rate and the people with years of dedicated experience sometimes don'thave a voice on how we can improve systems and protocol. At the end of the day everything is first looked at through the eye of will this cost the department money. In CT and fluoroscopy we always do a time out for any type of contrast or drug administered. The MRI techs should have also done this with the nurse. This is heart breaking because an individual who dedicated her life to serve others is now paying the price not just of her mistake but the sin pride and prestige of the VUMC.
Just Make It ....versed...should have never been ordered in the first place...second.... versed and Vecoronium..big difference.... horrific outcome.... everyone accountable from the doctor ordering it.... nurse not reading 5 rights.... pulling the wrong medication..questioning the order.... eye opener for all health providers
Yes, and without safety being a part of the culture then those who try and follow protocols are basically ridiculed and seen as a problem by staff and management.
Lizzy Tan Lizzy Tanny what you’re commenting makes zero fucking sense. Either you know nothing about this medications or you didn’t read the article or this is simply not your expertise. Goodbye!
Alejandro Zamora .... Wow...... idiot ...POS..... you want to battle come my way...... how old R....u fucken...Moran...... remember kid....karama come your way...... by the way I know my medication rights my dear.... versed vs Vecoronium...big freaking difference...... by the ways..you can keep freaking stupid comments to your staff...enough said
@@lizzytan277 nothing wrong with using versed for anxiety surrounding an MRI. Ativan is usually enough for most people, but if it takes a little versed it's better than full anesthesia IMO.
This terrifies me. I’ve had med errors before. So many meds to dispense, in such a short amount of time. Too many people with serious needs and not enough time to be everywhere at once. Passing meds while dealing with the guy with seizures and the guy bleeding out and the lady with dementia and the bells ringing and supervisors breathing down your neck. We’re expected to be superhuman and perfect all at the same time. It’s horrible what happened and I’m sure this nurse feels the guilt every day and will for the rest of her life. Jailing her is a terrible waste.
this deff. not encourages me to pursue my RN license. Oh no!.
You should sue them
The nurse made a grossly negligent mistake but that is just what it is, a mistake. I can't wrap my brain around how she is being criminally charged for this without any evidence that she maliciously intended to harm that lady. She already has to live with the knowledge that she killed a patient. There's no justification for putting her in jail without holding everyone involved with that case accountable. I always tell my EMT and paramedic students "you will make mistakes, just strive to be as good as you can be to avoid the BIG mistakes"....
Jason Wolf It’s called criminally negligent homicide. She didn’t intend to kill the patient, but nevertheless, through her actions, the patient is still dead. It’s difficult for me to understand how anyone could mistake vecuronium for versed. And yes, I do have actual knowledge of this; I got licensed in ‘85 as a pharmacist, worked in hospitals for years, mostly in the critical care areas. I was on the code team and worked in the E.D., so, what I know didn’t come from a book.
@@sharonthompson7557 I scrolled down so many comments before I saw someone, like yourself, say the most sane thing. I can't wrap my head around how someone mistook Versad for vecuronium. They don't even look alike sound alike, even if you compare to its generic name (Midazolam). The other thing is this RN saw Versad was not loaded but saw vecuronium and said to herself that was the med?!? Finally, I agree with negligent homicide. She obviously did not do it intentionally (I hope). However this is a mistake that costs someone's life at the end. It's no different when you had a moment of lapse in judgment by running a stop sign at 2AM and killed someone. You might be the best driver in town but it doesn't matter. The mistake cost someone's life.
That's why it's negligent homicide genius. And let's not mince words, that's exactly what is was. Read the CMS report if you can.
@@shannonlee2986 I read the report and did some more looking into negligent homicide and I see where they are getting the charges from. I had thought you had to be doing something illegal that caused a death such as DUI for it to constitute negligent homicide but a medical error such as this would qualify. Not sure why you felt the need to be an ass in your response but I'm not proud enough to not stand corrected when I misspeak.....
And when you behave recklessly and someone dies that is called reckless homicide and you get to go to prison for that
A paralytic should not be in any Pyxis.
Or maybe a separate machine that requires a code from the actual pharmacy dept.. How we do any ekit narc drug withdrawal.. Where I work....
Eh you’re going to need vec in the pyxis for RSI unless you work in a hospital where pharmacy can deliver RSI drugs in a minute.
It can be in pysxis but there should be a witnessed overide as well.
Or have it at a practice to scan the med and the ID bracelet... is that not a thing at Vandy? Just that step alone would have theoretically prevented this.
It should be in every crash cart and in the OR
CEOs make calculated cold-blooded decisions to increase patient to nurse ratios, patient to doctor ratios, mandatory utilization of higher & higher numbers of nurse practitioners supervised by fewer numbers of doctors. The administrations at many facilities singular goal is to increase the speed of the patient conveyor belts from the second they hit the ER. Caring for patients is viewed as nothing more than the processing of widgets. And you are surprised the administration threw this reputable nurse under the bus???!!! Administrations seek their financial goals while putting all the responsibility on the “providers”. Welcome to healthcare 2019. This scenario could have happened anywhere in the U.S.. I’m a hospitalist & I am sickened.
SO well said.
Finally a doctor who cares enough to take a stand for a nurse!!!!
There were plenty of doctors and nurses who disagreed with him.
Wow May God be with her. This is a tragic event on both side. I hope a jury doesn’t find her guilty . This scare me as a nurse .
As a nurse, I think this will only change when nurses and the nursing board stand behind a nurse accused of a crime the way doctors and the medical board stand behind a doctor accused of a crime. Doctors will typically rally around a doctor, but nurses will throw each other under the bus and "eat their young"
I hope that is the case because our culture is ugly in nursing, I hope we get further and further from the'nurses easy their young' mentality
Erika Ronska , I agree. My working experience is that nurses side with administration and tear each other apart.
Erika Ronska Yes yes yes!!!
As a nurse I do NOT stand behind dangerous idiots murdering patients
@@GinEric84 And if we feel that a mistake is not the same as murder than must mean we approve? Hop down from your high horse they buddy.
Also this was an error, if you can't tell the difference between error and intent, have a look at en.wikipedia.org/wiki/Genene_Jones as a comparison.
This is so scary. Kinda makes me want to hang up my RN hat. I cannot even imagine what this poor woman is going through...I would be in therapy also for the immense guilt. Administration at its finest, I totally agree with you and I shared this for sure!!
Hear hear.
So, you regularly ignore safety protocols and don't read labels before giving meds to patients? Cuz if so, please DO hang up your hat. We don't need negligent yahoos doing medicine.
Nieru yep, that’s exactly what I was saying....I give my patients whatever medication I feel like depending on the day without a care to safety and protocols....just wow.
@@LeeAnnMichelle04 well, I guess it's not the same thing, then, now is it? SMDH, God forbid nurses are expected to exercise a certain amount of caution and are held accountable for their negligence, right?
Nieru her negligence isn’t the issue. The issue is the criminal charges against her. There isn’t a nurse or doctor in this world that will honestly say they have never made a mistake in their career. Yes, this is the worst kind of mistake that can be made but there are other factors here. The nursing board did not revoke her license and she was not immediately fired or put on leave. Her firing and charges only came AFTER CMS threatened to withhold payment to Vanderbilt. If you know anything of state nursing boards then you know it can be pretty easy to get your license revoked or suspended. The fact that the TN BON did not do this is telling.
Coming at you with 100 % agreement in support if the nurse. Really appreciate your passion and support!
The reason the nurse goes to jail, is because somebody has to pay, and the nurse is at the bottom off the food chain without power so she's the logical sacrifice to get back to business as usual. It's about money, and protecting the elites, not the patients or front line workers.
What prosecutor would take this case?? I’m 100% with you sir!!
Yooper Gamer most
As a nurse educator for 25 years, I love not only your videos of parodies, (which I use in class) but most importantly your advocating for nurses. I wish we had more multidisciplinary teams led by people like you.
As a Rad Tech this is one of my fears. Not being able to clearly see or monitor my patients is not a good process.
Well said. I was caught in similar system failure that did not harm the patient, but lost my job of 12 years anyway. I can't imagine what this nurse must be going through. My heart goes out to her
I agree with you 100%, she has paid and will continue to pay for the rest of her life, she dont deserve this, accident will always happen but this is not the answer at all
It wasn't an accident, it was gross negligence
Nurses adapt to poor staffing with short cuts which remain even when staffing is okay. Something has to give when you have too many things at the same time to do in reality, but all the management cares about is the charting and joint commission. It is dumb luck that horrible errors don't happen to more people.
As an ICU nurse 24 years what I can’t get out of my head is that she reconstituted a drug that she thought was Versed. Any seasoned nurse knows that Versed is not reconstituted. When she was required to reconstitute the drug that she had pulled that should have been a warning sign to stop. Also who pulls a drug and doesn’t look at the label? That being said a lot of the blame should be with the hospitals with their unsafe staffing ratios and their lack of institutional controls.
Also, brand names are never used in Pyxis as well. Only generic
Absolutely agree with ZDogg's message. This will make patients less safe, ultimately, not more.
2nd year medical student here and my heart goes out to this nurse. Completely agree with you Dr. Z.
Every RN's nightmare...hospital will throw u under the bus in a NY minute! Thank you MD Z......Blessings and healing to this nurse.
My worst nightmare is not the hospital not having my back if I murder someone..
Just juxtapose cops and nurses for a sec. If a cop shoots someone to death by mistake thinking the suspect might be a threat, even in a non-threatening situation, the cop goes off scot-free most of the time. Now this nurse is being for charged for reckless homicide, for making a mistake. Both come from broken systems, one is allowed to go free, while the other is held accountable only to cover up the faults of the hospital. Absolutely disgusting and inhumane.
This is not "a mistake".
This was a number of reckless and blatant errors on her part in violation of hospital policy and nursing standards of care... let alone common sense. If she had grabbed a similar look alike/sound alike drug, I could see "a mistake". But overriding warnings, ignoring a large PARALYZING AGENT on the RED CAP and reconstituting a medication that I don't even believe they make in an reconstitute (let alone routinely stock)... that's a special kind of stupid. That's EX-NURSE level of incompetence.
@@Critmedic Last time I checked, human error is a mistake. A nurse, who was out of her normal element/working environment mind you, tried to do right and help a patient feel more at ease during a scheduled procedure. Who knows what her patient load was that day? There so many unknown variables in regards to her mental state, from level stress to lack of sleep or even if she had time to eat something that day. No one saying that she was in the right or she didn't do anything wrong, all we are saying is that she shouldn't be the one taking all the blame for a failed system and a hospital that tried to cover it up. Would you jail every doctor who prescribed opioid in good faith, whose patients later die from taking them?
Agreed. One more difference: the cop knew he was killing someone. The nurse thought she was helping someone. Now judge away.
Leonid Sigal It isn't just a mistake. It was a CARELESS mistake. She didn't follow the safety protocol that needs to be implemented before any drug or treatment is given!
Leonid Sigal No. It wasn't just a mistake. It was failure to go through the proper safety steps. That is emphazised in nursing school! She refused to implement them. There were MULTIPLE failures to implement safety steps.
Thanks for being supportive...healthcare needs all catergories of caregivers working together...un fortunately there isn't any backup from management or administrators in hospitals for the caregivers..it's gone from bad to worse in the 30 yrs of being a RN..I'm so glad I'm retired now
And this right here is why I love ZDoggMD!!!
Thank you so much for your support for nurses and other medical staff. I’ve been a nurse for almost 5 years and the worst part of the job for me is the verbal and emotional abuse from patients and their families, and occasionally doctors.
I really appreciate you
Do you wan a culture where nurses cover up every mistake they make and the system never gets fixed? Because that's how you get a culture where nurses cover up every mistake they make and the system never gets fixed
I don't know what video you watched, but no where in this video does he imply or even state that mistakes should be covered up. I'm unsure if you're a troll or if you're actually serious in saying something like that, because its completely uncalled for and out of place for the point that is being made in this video.
George Blevins
Rewatch the video
Because he made just that statement
George Blevins At 7:01 he says exactly that.
@@justmeveginout8864 @This Video @John McClain no, you are all three very, very wrong. He stated 5 seconds later that what we need is radical transparency. You guys are the types of dudes to clip 5 seconds of a video and take words out of context to burn someone. It's literally disgusting. Now I ask, "WHAT VIDEO DID "YOU" WATCH."
@@metalhead4404 are you a nurse? Probably not. Medical errors are very common and the action by the legal team is unacceptable. Every single person in charge of the system etc. should be arrested too. The physician, pharmacist and the administration. You CANNOT blame the nurse for a system issue; remember, that starts at the top. Also, a system should never allow someone to override a NON-LIFE SUSTAINING medication. Once again, this is a system issue.
The fact that Vanderbilt hasn't changed their processes in over a year per CMS is a blatant sign that Vanderbilt Administrators should have been arrested instead!
This is getting absolutely crazy! I believe if they arrested her, they should hold everyone accountable, including pharmacists, administration, and doctors.This is crazy!
No, it was her fault because she overrode the drug. She's the one who blatantly did it, not the other people.
Why should the pharmacists be accountable? She overrode the pyxis, pulled the wrong med, RECONSTITUTED the wrong med while IGNORING the BRIGHT RED PARALYTIC LABEL, gave the wrong med with zero follow-up assessment. EVERY SINGLE one of these steps, if she did the right thing, would have prevented the death of this patient. Administration?? seriously?? Did they tell her to go and do a shitty job and kill a patient? I seriously doubt the doctors told her to do that. This is all her responsibility. She KILLED a patient with SLOPPY nursing practice in about the most horrific way possible, on Christmas Eve of all days!! She overrode the safeguards and REFUSED to abide by her training. At some point, "just" culture becomes "victim" culture and allows the sloppy and irresponsible to squirm out of accountability.
But how can they hold her accountable when they don’t focus on blame they focus on process improvement.
Crosby Steen, MSN, RN ...if she pulled the med from the Pyxis, is there a way the pharmacist have prevented this?
@@melissahahn4779 Not at that exact moment. I'm saying that the pharmacy policies such as better labeling may have prevented it. Or it may not, the point is that there is blame to be had everywhere.The nurse should be held accountable ,I just think arrested is too much.
I have been a nurse for almost 30 years. I have also read most of the replies to this video. First, reporting of medication error or medical errors in general are supposed to be used for quality improvement. Nurses etc. are not supposed to fear reporting an error. I find it funny, not really, that some people are damning this nurse for her error. Mind you, it was a doozy but she did not try to hide it. It was reported in good faith. She has probably suffered more since this happened by beating herself up by not following proper protocol, probably has suffered from guilt and depression since she realized what happened. But the bottom line is it happened, and we all have to learn from it. It is my understanding that she was floated to an area she was not entirely a costumed to. Her patient, whether going to CT or MRI should have been on a monitor to travel and should have been placed on a monitor in either radiology area she went to. It was not just her responsibility, there were others present.. You cannot tell me that a complete body scan would not have shown her not breathing with or without a monitor. The Radiology techs often talk to the patient during the scan, did no one ask this patient if she was ok during the scan, noting that she did not respond? A whole body scan for a subdural hematoma makes no sense. Why would they do that? The problem was in her brain... there are many questions I would ask. How much Versed was ordered? If she was unfamiliar with the area was she also unfamiliar with the critical care meds(versed is a critical care med), did she not know the generic name? For those of you that don’t, it is midazolam.... not even close to versed.... maybe the doctor should have known how it was written in the Pyxis ... maybe he should have ordered it that way.... if she was unfamiliar with Versed, maybe she didn’t know it didn’t get reconstituted.... she did not show malice.... if her defense needs an expert witness... they can contact any nurse educator that is not employed by Vanderbilt.... she should have had to go through training again to refresh her, but she should not be prosecuted
Any one of us could have made this mistake... I’ve been a nurse for 10 years and know that everyday things happen that could be avoided. I can’t imagine the pain and suffering this nurse is already going through! I would absolutely be beside myself if I made this error. You’re absolutely right... we need a system where we can honestly come forward with mistakes and problems... not prosecuted for them. We want to keep patients as safe as possible and not cover up the problems.
As an ex NICU nurse at REgions Hospital St Paul we were forced to take mandatory overtime. Even when expressing the inability to do a total of 16 hours with a 1-2lb infant and 5 + IVs going we were told it would be abandoning our duty and calls for firing! I put up with that for years! No parents ever knew. I’m sick for this nurse!
There was a nurse in Wisconsin Juile Thao That felony charges were brought against for overriding safety procedures. This was in 2007. It was found she worked a 16 hour shift, slept at the hospital, and worked again. More needs to come out about the kind of work environment is at Vanderbilt. I will be following this closely! The whole situation is scary! A quote from Diana Richardson RN from the Wisconsin Hospital Association stated "health professionals enter Healthcare knowing that a mistake could cost them their license, livelihood, and financial stability. What is incomprehensible is entering a career where a single error could lead to imprisonment" :-(
Very well said.
I totally agreed, Truck drivers are closely monitored for their sleeping patterns, that should also be the same for nurses. Also safety protocols no matter the fast placing.. They need systems to safety dispense meds to nurses after being signed by doctors, yes If a doctor gives a verbal order or Witten order, the machine needs its approval as well. That way the Doctor can be also accountable; and this would give the patient an EXTRA LAYER OF PROTECTION.
I am glad I am almost retired. Practicing medicine in America has become terrible. From administrators 'practicing medice', to corporate ownership stealing physicians compensation and now criminal charges for medical mistakes, the system is already ruined!
So who/whom are the parties pushing criminal charges? The patient's family doesn't want this, she has credible character witnesses and assuming her record is clean & clear I just don't see it. I'm pretty sure the District Attorney's office has more work than they need right now. So did they just "pick" this case out of the blue? I'm confused.
The District Attorney is looking for easy victims to increase his "cases tried" list. Nashville's DA is Glenn Funk, who has an interesting history in that he has prosecuted professional women on inflated charges numerous times. In February 2018, he forced the resignation of Nashville mayor Megan Barry over what he described as an "illegal" affair with a police officer. Then in August, HE was pulled over and issued a citation for speeding in a school zone DURING school hours. He's a real advocate for safety, that's for sure.
@@activeobserver6503 Thanks for the information.
Tennessee does not need a willing victim to press charges. It *may* come in handy during abuse cases when the victim, with obvious injury, is too afraid of the abuser to speak out. BUT... I don't feel this case in the slightest is the way to use that rule.
@@shannonedna5241 Right! The criminal charge doesn't fit the situation. If this were to set a president then the healthcare and justice systems would both fall apart!
@@shannonedna5241 Apparently Tennessee doesn't need willing nurses either. Tennessee nurses consider moving out of Tennessee and memorize the name of this prosecutor when he shows up for treatment, REFUSE to treat him.
I'm living for your RAGE. How dare they throw her under the bus!!! She already paid for this egregious mistake.
I don't think I even want to be a nurse anymore. Your waiter screws up, he gets a small tip. Your nurse screws up, she goes to jail. Why?
TheVillainOfTheYear because the nurse consciously screwed up and a patient died??? Little different than the wrong entree being brought to your table
No different. Human error will always exist. How about the lives that nurse saved? That gets her nothing?
Because people suck.
I’m not arguing whether or not she should go to jail, just that you cannot compare the error of a waiter to that of a nurse. It’s a different scale.
Ummm... because she killed someone?
Well said Z. This nurse will never recover from this. Anyone who has ever taken care of patients has come close to or done something similar.
It makes me sad but I wish I could love this video a hundred times! THIS is exactly the type of administrative response that makes me very adamant, when training new nurses, about the importance of your own malpractice insurance. Your hospital may say they have insurance on you but when the chips are down, they will throw you under the bus to cover their own behind! Unfortunately that insurance doesn't protect from criminal charges but it will be the best $100/yr you spend. So so many things wrong with this whole situation. We clearly don't do this job for the money. It's a passion and a calling. Nurse/patient ratios, length of stay, little protection on the front line, long hours without breaks, lack of respect between departments and doctor and nurses, poor systems all play into the likelihood of these mistakes becoming more frequent. Our system is already broken and will only be more irrevocably damaged if they successfully convict her.
#IStandWithRadondaVaught
Thank you ZDoggMD for your support of the Nursing Community! We shall not break!
What a joke. Every prospective doctor and nurse in the country needs to pay attention to this. Go through intense schooling, get into crazy amounts of debt, work yourself to death for the good of others, get thrown in jail when you make a mistake that there should be a litany of safeguards to prevent. Good luck kids, Telehealth here I come.
Medical student here. I am thinking about jumping out of medical training but am drowning in debt. I try my best... but if that best is gonna get me in prison (no one is perfect) then no thank you.
Safeguards... you mean like the medication dispensing cabinet that required a specific override to obtain that medication? Or the hospital policy requiring verification by another nurse? Or the hospital policy and nursing standard of care requiring you to monitor your patient for response to medication (especially as either intended and accidental medication are considered "high risk")? Or perhaps the safeguard of common sense that should clue you in that if you have to suddenly reconstitute a common medication that you NEVER had to reconstitute before so perhaps one should double check that that is indeed the right medication? Or perhaps the safeguard of the RED CAP with "PARALYZING AGENT" written on it in large, capital letters in contrasting color?
But you're right. More safeguards. Apparently, you can't rely on the concept of a trained nurse with a functioning brain.
CritMedic Should have read your comments before; I wrote pretty much the same thing. I’m glad that I’m not the only one who finds this incredible.
@@sharonthompson7557 and CritMedic, Nurse here-I agree with you about the egregiousness of the errors made by the nurse. However, I don't think criminal charges are the answer. Loss of license and civil penalties, sure. Jail? No. JMO.
@@shawnreed7876 I know a friend who was an LPN and after multiple problems she gave it up for a union school custodial job. Made more money & just retired. Too many jealous female nurses who delight at throwing others under the bus.
Retail pharmacist here. A few years ago I grabbed a box of duoneb thinking it was budesonide and overrode it to save time. Turns out the patient had a non-severe allergic reaction to the albuterol and chose to visit the doctor, discovering the error. The patient returned and notified me of the error and I was mortified. It brought tears to my eyes. Fortunately, she was one of the kindest patients I’ve ever had and she insisted that I not hold it against myself.
The morals here IMO are 1) we all make mistakes. Sometimes they are minor, sometimes serious. The factors that determine the seriousness are often beyond our control. 2) Always express remorse and apologize sincerely. Most reasonable people simply want an apology and do not want to destroy your life
3) learn from your mistakes. When similar scenarios present again, remember those past patients to help you avoid the same errors.
Her arrest will have an unintended consequence of worsening quality by hiding medical errors as opposed to trying to solve the multiple system errors which are typically the problem.
Zdogg, you make so much sense about healthcare priorities and the atrocities of healthcare today. I listened to your “burnout” video and it woke me up to how I have been feeling lately. I left healthcare for the very reasons you mentioned. Thank you for being a voice of reason.
This RN is with you 100%! This never should have happened, but I totally understand how it did. The fact that a patient receiving even the slightest sedation for an MRI was not being monitored is mind boggling and terrifying. My heart goes out to that nurse.
Disagree. It is the sheer LAUNDRY LIST of errors that she made that makes HER accountable. If she had used her nursing training AT ANY POINT in this sequence this woman would still be alive. 1: overrode the Pyxis 2: pulled wrong med from Pyxis 3: reconstituted a drug and ignored THE BRIGHT RED LABEL THAT SAYS PARALYTIC!!! 4: versed does NOT have to reconstituted!! 5: administered said wrong drug and walked out without assessment!! If she had stayed 2 mins that would have been enough to know the patient was crashing! This scenario tells me she had ZERO clue about the drug she was supposed to be giving and didn’t bother to take the time to look it up or, HELL, call the PHARMACY!! Who the hell gives an IV push sedative and just walks out and leaves the patient??? Here we don’t give Versed outside of conscious sedation which means continuous monitoring. So...Using your argument... we should not punish accidental deaths because there was no intent to harm. Should we not punish drunk drivers when they kill someone?? What about people that accidentally hit and kill pedestrians?? I don't hear any calls not to punish these people because everyone knows that the deaths are mostly preventable when vehicles are operated as trained and in a responsible manner. The same applies to this scenario...this was preventable and because she acted in a way that was contrary to training and irresponsible someone died. This was not just ONE med error...it was a series of tragic F-ups!!! Quite frankly - you are all giving her a pass because you are superimposing yourselves into this situation... you don't want her charged because, in your own minds, you are covering your own asses. Quite frankly it's disgusting and you all should be ashamed. You all want to talk about precedent?? What kind of precedent does this set if she is just allowed to go?? It tells our patients that their lives are not as important as our individual freedom and that when it comes to errors, we would rather stick together than stick up for them. It tells future nurses that it's no big deal to make dangerous mistakes because they will just get bailed out by their fellow nurses because we got each other's back. Not this nurse.
This !! We have a responsibility to hold each other accountable ! This was Negligence not an accident !
That’s insane!! Heart goes out to the nurse and the family! I’ve made a mistake or 2. There shouldn’t be a way to override without a second pair of eyes. The national shortages alone should make it clear that we need the system and the processes to have our backs. We are humans!🤦🏾♀️
Yep!
at Ohio's Hospice of Dayton (4th palliative IPU in the nation), they DEFINATELY have charge RN the only one who can pull override drugs! And is 2 RN witness...
@@Hopeof7suns crazy, so what are you saying?
Maybe we should start refusing to provide care if they make these impossible conditions. Then the whole system will break because it’s like that everywhere.
While no one can cast ANY stones at this nurse, I must, MUST say that when you look up a med and it doesn’t pop up, overriding the system was not the next logical step. When I’m trying to put in an order or grab a med, if I can’t find a mess under the commercial name, I take the one second and google that med. it usually gives you that name you looked up, the generic name ( which may be what you need to get the right med) and several other names it COULD be. The other errors were, yes, a result from a faulty system and overworked and rushed, but what I don’t understand is why she didn’t check for the generic name of versed.. even if she’s on older nurse...there’s a drug book in the med room, most likely... or go ask someone! “ hey I’m trying to pull this med and it isn’t coming up. Can you help me?” I believe this one not-checking-generic-names things was the downfall. I’m a fairly new nurse and I know I have years and years to learn, but even now, if I don’t know something or something doesn’t look or feel right, I look it up, or ask someone else until I have the appropriate treatment for the patient...I too am very overworked and underpaid and my plate is too full also....but Im still gonna make sure I’m doing the right thing. Please learn your generics WITH your name brand drugs!
Well said! I follow that motto of always asking for help when I am unsure of things because there is a life at stake.
In my view as a nurse I have the fullest respect for the pyxis machine and all the medications in there from the first day I was rrained and ongoing I bring my computer on wheels and verify the medication per the mar. I respect all nurses and the feeling this nurse is going through I pray over her and all medical staff. What we do is not easy and at times it is down right nerve racking but God gave us these to hands to nurture heal and hold. Be blessed my fellow nurses.
Wow!! My heart breaks for this Nurse!! Sending my thoughts and prayers to her and the family effected during this time💔
"the family effected" = the family of her victim?
Thank you for standing up for her. I really appreciate this video.
I agree 100%, ZDogg. It's ashame; another case of administration throwing staff under the bus. Despite my thoughts on the errors that occurred, I think it's absurd for her to have been arrested. No grounds for a criminal case, and just torturous to the poor nurse.
Thank you for standing up!
Zdogg your my hero I agree fully with you. I hope she does not get jail time.
The more I read the more upset I get... The nurse was hired for an ICU in Oct 2015, she received her license in February 2015!
How in the hell did she have enough experience to be an ICU nurse? Fast forward about 2 years and something bad happens...
I looked at the job posting for a neuro ICU nurse and found that they only require 6 months experience, so I guess she had that... it also mentions that the unit has "charge nurse help all" so does that mean she was a charge nurse?
After this happened, Vandy did not report this sentinel event (required by law), hid it from the ME, settled out of court with the family (with a NDA) and fired the nurse.
The hospital only took action (other than paying off the family and firing the nurse) after there was an anonymous complaint filed with CMS and the investigation from CMS found that they were in violation and if they did not fix it they would lose CMS $. That got their attention, so they revised some policies, changed what meds can be removed with an override, and outlined a plan to train nursing. And it only took them just under a year to fix their flawed system that set up the conditions that allowed the nurse to make her error.
So the hospital hid evidence, failed to report, and only changed the system when they were called out, by CMS, with the threat of lost income... but the nurse is the one being charged with a crime. What about the administrators? No charges for falsifying records? Failure of their duty to report? Attempting to cover up the incident?
No? Why not? Because a nurse who makes about 50-70k/year is a much easier target to go after than a hospital admin who probably makes > 150K/year and gets bonuses = to a years pay for a nurse.
Now I see that she has lost her license, and is being fined $3000 and is responsible for "costs" of up to $60,000... plus she has to pay her counsel, and still has the trial to go.
And people wonder why there is a nursing shortage...
@ZDoggMD how about an update video?
Job posting: vanderbilt.taleo.net/careersection/.vu_cs/jobdetail.ftl?job=2000144&tz=GMT-05%3A00&tzname=America%2FChicago
Board of Nursing order: apps.health.tn.gov/Licensure/DisplayPdf.aspx?profCode=1703&LicenseNum=205702&ActionDate=7/23/2021
I am sorry for all my fellow nurse practitioners, nurses, PAs, and MDs. A culture that criminalizes mistakes will hide those mistakes. We should learn from those and continue to find the root cause of these. A common goal of safety and shared knowledge is needed to prevent future mistakes. I am profoundly saddened by this news.
As a nurse, we are encouraged to report all errors, including potential/near miss type errors (i.e. Wrong drug in a Pyxis pocket, etc). I have reported on MYSELF before, as we're taught, to monitor and implement changes to improve PATIENT safety, without fear of retaliation. This kind of stuff, the firing of the nurse, then criminally charging the nurse (hello? Intent?) looks an awful lot like retaliation. This is what prevents reporting, increases fear and covering up incidents, leading to continued patient harm.
Who, in their right mind, would ever want to be a nurse????
Responsible, competent people :)
(20+Year RN here)
agree with you Dr. z
Thank You for being this situation to light..
so many mixed emotions, my heart hurts for everyone involved!
Making mistakes as a nurse stays with us forever .. prayers and 100% support for you Rosanna (so sorry if I misspelled your name)
I love the research and light you shed on this. I can't agree more.
I missed a sepsis in an 11 month old child. It was one of those nights, waiting room out the door, patients lining EVERY hallway, some in chairs, most on a stretcher. I told the nurse to send in labs. The kid looked ok, but sleepy. I gave them explicit instructions to bring this kid back if ANYTHING looks different or worse. Lucky for me and the kid, the parents brought them back, with spots and a 104 temp. This happened while I was off duty, but the phone was ringing, and my supervisor told me what was going on. He thanked me for doing good patient returns if changed, and it was the worst week of my life. The patient got airlifted to San Francisco General and from there I lost track. I worked nights for 15 years, in the ER, seeing as many patients as was possible. Prompt Care for 6 hours and then Trauma for the other 6 hours. Nurses are the glue that holds this system together. If you start arresting them for working their asses off and making an error, everything will come crashing down. In defense of this nurse, a paralytic should not be in with the usual drugs. There has to be a way to separate them. I’m a PA so I did not have access to the drugs, I already had more then I could do anyway.
No i do not feel she should go to prison for what happened .. It was not done on purpose .. This is so sad i will pray for her she desrves better then what is happening to her
Work for a similar university medical system and our CNO has told us that safety reports cannot be discussed because they are a private matter. I have brought up that what I was taught in nursing school was that the purpose of these reports is to investigate areas that need improvement and how is our unit supposed to improve if changes are not made and mistakes are not discussed among the team to avoid them in the future.... crickets....
I love that you can publicly lay out the “system errors”, identify professional errors, and their attempt to charge one administrator. Errors are made in “practice”, normally without intent, hence, a mistake. As health professionals, “we” understand the holes in the process that continue to plague our ability to provide safe care. Nurses already are stretched thin, there is a national shortage, and rumors hold that “we eat our own”. The system will quickly deteriorate if we instill yet another reason why nurses will fall away from the profession.
I am in complete agreement with you on this 10,000%. I am an FNP with an extensive background in critical care. The self righteous police state which arrested her and the administrators above her should then share that prison cell. Shameful. No matter how Vanderbilt "handles" it, this one act alone negates any "good" thing they do. Filthy. Disgusting. Black mark on Vanderbilt.
Throwing this woman under the bus will not fix the system or the problem. Fix the problem. Make it impossible to put a sedated patient in an unmonitored bed. Make it impossible to pull a paralytic by accident. Throwing her under the bus only allows more accidents and problems . Prosecution of her fixes nothing and allows a broken system to continue “ as is”.
Make this accident impossible to happen again and you will save lives.
This woman is being prosecuted because she is human . Humans are not supposed to be perfect. They can’t be.
The administration is paid big bucks to create a system the leads to safer care. Clearly they have not done so.
she is the scapegoat which also happens to be the low hanging fruit. she is completely innocent imo.
A dog wouldn't work under such punishment. Paralysis of decision making and fear of punishment degrades the ability to provide proper care. The institution is sacrificing her to deflect attention from their flaws, and nothing will change.
I agree, this was not a deliberate homicide or reckless abuse. The systems for safety; the Pyxis and on-going procedural assessment, weren't in place. Sure nurse Vaught is partly at fault, but this was a mistake, not a murder in cold blood.
I couldn’t agree with you all as well. This was a systems error resulting in a terrible incident resulting in at least two victims, more when you count family and friends, and now what does Vanderbilt do, compound the situation and make another systems error; in addition, I think they’ve made a moral mistake, sent and sent a terrible message to all of their staff indicating that what little they did care for them was conditional, all mistakes maybe punitive. They clearly learned nothing rom he event. I think this will add to staff suicides. Doctor’s, nurses, RT’s, CNA’s, and techs give their heart and souls to their patients and the general public has no idea what we really do and what we are legally responsible for. Zdogg MD you saved me though,! I was going to attend Vanderbilt for APN school, I am glad I am not going to! My prayers go to the family affected and this hard working nurse who made a human mistake!
I completely agree. Coming from someone who has had a family member ACTUALLY murdered for real. So sad for both parties. So pathetic for the whole system she worked for.
Leadership will never held accountable and that's the biggest problem!
It is so disheartening that nurses do not really behind our own. We should be in the streets with signs and bullhorns behind this. The conditions and stress this RN was under led to this mistake happening. We as nurses need to fully educate the public on the realities of healthcare....the constant understaffing, increased patient load, increased charting requirements, pressure to "make the patient happy at all costs" even if its contrary and detrimental to the patients BEST interest. Not even counting the system failures incorporated in this. My heart goes out to this nurse. And I agree this is ridiculous, scapegoating and gaslighting personified.
Well said and all true.
Preach it Z!!! What really needs to happen for a true overhaul if the system is for Medicare and Medicaid to pull funding/ payment for any hospital that cannot adequately prove and show ongoing record of administration/ leadership, as you put it, enacting and monitoring good medical practices that are GOOD FOR THE PATIENT FIRST and not for profit margins. Any hospital that puts profits before it care should be shut down. Sadly, that would probably be most if not all in the US. What a complete tragedy on all fronts!!
We're gonna end up with no medications being able to be overriden in pyxis/ Omni machines. Arrest / criminal charges will not help. It will make hospitals and health systems be less open about errors. Reminds me of the pharmacist in Ohio that made the error in chemotherapy for a pediatric patient.
I want every hospital administration to spend a day in the shoes of their nurses and see how they feel about the things they implement. After I became an RN and worked hospital I hated it! Maybe I'm not tough enough but I really struggled with being in a place where I was bullied, unappreciated, and expected to know everything as a new grad (left out to dry with 10 patients of my own). I stand with this nurse who obviously feels extreme pain and guilt and has been kicked to the curb because this hospital doesn't want to loose it's money. That's all the hospital cares about, they don't care about the patients or their employees, just $$$$$ that they make. It's disgusting how she's being treated for this.
I also know cases where doctors have caused great harm to patients ON PURPOSE and have just casually moved on from that hospital, not brought up on charges, and now own their own practice like nothing ever happened.
Well said, Doctor. Unfortunately, there are no leaders. An epic tragedy on all sides
Agreed. Thanks for being a voice for our medical community!
I agree with you completely based on the facts that are known/disclosed. Scapegoating this nurse by indicting her when she has already paid the high price of job termination and mental anguish is cruel. Furthermore, it points to a healthcare system that is unwilling to take an honest look at the multiple system and process failures at play in this tragedy. Whatever CAPA plan was submitted to CMS, it was likely superficial, especially considering how reluctant the institution is to release it to the public. If they truly addressed the root causes that led to this patient's death, why not be transparent and disclose it?
I support you too Radonda. It's unfortunate that so few people in leadership are actually leaders. She should only be in jail if she did it on purpose. Thanks for supporting us Z
My biggest complaint about incident reporting systems is they can be used against a person either vindictively by a fellow employee or by management even though the process is not supposed to involve punishment. The overall goal is correct but the process is flawed. They should make reporting systems anonymous, so it can’t be used punitively against the person(s) at fault if the overall goal is to correct flawed policies.
Currently hospitals use the polices to deflect financial responsibility which they won’t get out of unless there is extreme gross negligence which will be reported by other methods anyways.
It’s always about the money.
Incident reporting can't be trusted at all. It makes one constantly on the lookout toward their fellow co-worker & leaves a negative vibe that no one can be trusted. Worse environment to work in. When trust is gone, then safety becomes a greater concern. Any incident needs addressed at the team level.
Without reports with names you can't see what staff are duds and get them out.
Has the American Nurses Association stepped up to advocate for her?
I recently retired after 42 yrs of nursing. I started each shift asking God to keep me from making an error that harmed someone, or worse. It is every nurses fear, and it’s only by the grace of God that I got through it.
Nursing is the only profession I know of in which one is held responsible for the actions of those above us and below us as well as ourselves.
I appreciate your support for this nurse. I never encourage anyone to choose that profession (neither do I discourage it). It’s not for cowards, that’s for sure!!!
Making errors a criminal offense will not help the nursing shortage nor will it attract quality people to the profession. 😕
I agree. There was so many system errors this horrible accident is not criminal. My heart goes out to her.
I'm completely agreeing with you. I'm a neuro RN and this scares me. How can they possibly put a caring nurse who made a grave error in prison?!? This is crazy
I tend to agree with ZDOGG on this one. The five rights of medication should just be a coaching and counseling session for her and the fact that she went on unmonitored in radiation speaks more about the protocols that are put in place that need to be re-valuated by administrators
Not by administrators, they are focused on money. healthcare needs to replace these administrators with clinicians who know nursing care as more than a cost.
I am a Nurse here in Nashville at a different hospital. We are following this story very closely. My first question when I hear blame of a nurse is; How many patients was this nurse caring for at the time? What was their acuity? How many other jobs was she doing? This is a problem across the country, there are no laws in place to protect the nurse or other healthcare providers from being greatly over tasked. We do the best we can do for our patients and continue to adapt. This will continue until a great tragedy gets national attention, or we stand up and force laws to change. I encourage all to look up safe nursing ratios and what bills are in senate to support them. Make the noise to get these bills approved 😊
This is tragic for everyone involved. Yes the nurse bypassed the system and made grave errors. But what happened to needing a co-signer when overriding these kinds of meds?? My thoughts: the nurse should be held accountable but not as a criminal. Maybe license suspended with extensive education and counseling, then be able to return to the bedside with a probationary period. The point is that it seems to have been a mistake but not malicious or purposeful. This has gotten to me down to my core. This also has me questioning whether I want to continue at the bedside. I am very careful and follow safety policies but we are still HUMAN. The direction healthcare is going...is it even worth it anymore? May God be with this family, nurse and all involved.
Omg you took all the words right out of my mouth. This story is haunting me, literally. To the point I wonder what I’m even doing anymore. Errors or not, do I really want to work in this system!?!
As a nurse myself this makes me absolutely terrified for a multitude of reasons. I absolutely agree with you about how this will make people cover up errors even more. I have so much stress every single day about going to work and making a mistake. The stress of being a nurse is REAL because of the fear instilled in us that things are our fault since we are the front line.
I’m sure 12 hr shifts don’t help this situation. The 8 hr workday was put in place for a reason.
Actually, research shows that 12 hour shifts increase patient safety by reducing the number of staff handoffs in a 24hr period (2 handoffs vs 3) while still being a manageable shift. Anything beyond 12hr, like when nurses are asked to "work late" and cover a 16, I agree with you completely. But a 12 seems to be the sweet spot between not too long a shift and fewer staff handoffs.
I agree with you, Z! I support this nurse, she has suffered enough. I have been an OB nurse for 25 years now, and I understand the stress of tragic incidents. Each baby that is born with my name on its chart, I'm liable for 21 years!!!!! So sad for this nurse and her family.
modernization and automation should remove the room for human error. if a system allows room for a human to make mistake, then that system is broken. I think it is unfortunate that this event happened, but punishing the people involved in this accident would just be masking the symptoms. We should address the causes of this accident which, in my opinion, is systems being developed or influenced by people not working in the field it is deployed in. Should she be punished for her mistakes? If the family says no, then they should honor their wishes.
Sometimes, some of the onus is on the administrator of the drug to make sure they actually obtained the correct medication. Overriding technological safeguards and blatantly ignoring ANY of the writing printed on the vial... I found the cause of your accident -- a bad and incompetent nurse. One that broke hospital policy and nursing standards of care.
CritMedic I couldn’t agree with you more. Well said.
Yes we need the ability to override for emergencies. At that time the administration is in the hands of the person giving it. That is when you have to go back to your five rights and armband verification and when possible two nurse verification on a drug like that.
100% agree! Thank you for speaking my mind 👏👏