What went wrong in the RaDonda Vaught case and 'Just Culture'
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- Опубліковано 4 кві 2022
- UPDATE: Much has occurred since this video originally aired. Hear RaDonda's personal account as a keynote speaker at our annual Global TapRooT® Summit on April 26, 2023. Find more details here: www.taproot.com/summit/keynot...
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Emily and Marcus discuss the trial of RaDonda Vaught, a former nurse, where she was convicted of 2 felonies for fatal medical error. We walk through the TapRooT® System by building a SnapCharT™ to show the FACTS of the case and our thoughts on Just Culture and the outcome.
Referenced USA Today Article: www.usatoday.com/story/news/n...
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This nurse was crucified ! She was set up for failure ! If a Doctor makes a mistake , he ends up practising in another State .
The lesson here for nurses is to keep your mouth shut , and get a lawyer , STAT !
Love this! Great place to get the facts and to learn how this could have been prevented.
There was no order to ignore a nationwide standard of care. Period. The doctor told the family he'd look into it. No verbal or written or er was transcribed into the informatics.
Wow!
Accidents are unavoidable, this was not an accident. This was extreme gross negligence and professional incompetence on the highest level. It’s like saying I accidentally hit someone with my car, but I was drunk, high, had bad brakes, no inspection, no license, lights not working, broken windshield…but sure it was an…”accident” sorry but she’s guilty
Just culture vs blame culture.
I just came across this video... you need to create one of these for Covid vaccine vials. As a vaccinator, we have multiple vials we are drawing from (depends on age group and whether immunocompromised). Pfizer manufactures both monovalent and bivalent vaccines that have the same color vial and vial cap. Moderna has a "magenta" vial and Pfizer has a "maroon" vial (very similar names and colors). Several of the vials have blue caps. Children who turn 5 during their primary series jump to a different vial. Many RNs are refusing to vaccinate with Covid vaccines because it's become so complicated and they are afraid of making a mistake.
The "thought process" that someone in the organization ALWAYS puts first is cost, not patient safety. The reason they don't have a scanner in radiology is because they are expensive. I have pulled policies and shown them to my supervisor who has said "this department doesn't follow that policy" because the policy is inconvenient. If we did the 5 rights/3 checks every single time, it would slow us down and they'd have to keep us well staffed. We report near misses and hear crickets. I am so happy I don't have to work inpatient.
ugh so much tip toeing around the elephant called negligence
Warning. This video is about selling product using the R. V. case. I have 25 years at hospital bed side care, 10 of those years in Neuro ICU and stepdown unit. Who is the girl wearing a lab coat and stethoscope? Not all facts stated are correct, some of the guys statements are off. I have also read the federal/CMS report. Also clinical educator for 4yrs. Hey TapRoot if you need help with editing content let me know.
Where can we access federal/CMS report at?
To add clarity, the reason I am in a lab coat and stethoscope (my personal items from my professional experience taking vitals) is to express personal ties to how this case affects many individuals-my immediate family includes healthcare professionals working as a family nurse practitioner, a pulmonary thoracic critical care specialist, an anesthesiologist, a clinical social worker, and an Army nurse. This case hit home for all in the #IamRaDondaVaught movement on social media at the time.
While I appreciate that you believe you are well intentioned - there is far more to this story and performing a complete analysis than relying on only those facts made public. Please remember that there is a lot more that is not released or readily available that will impact the analysis. During litigation the attorneys only present the facts to substantiate their respective positions and not all of the facts. You cannot say with 100% certainty that each one of those mistakes are due to a lack of processes. There are all kinds of other contributing factors.
Until legislative changes are made, and well-intentioned software vendors are participating in meaningful changes accidents like this will continue to happen.
Good point. It would be nice to have all the facts of a well-investigated incident with a thorough root cause analysis using TapRooT RCA. ut Marcus used more than just the testimony presented at the trial. He mentioned the report produced by the Medicare Administrators and facts released by the hospital.
I agree that more information will always allow you to get a better understanding of the event and will help improve your analysis. And that your analysis should only be done with hard facts to eliminate blame and bias. We only had what was available to the public. You would never want to speculate and put out an analysis not back by evidence. Therefore we used only the facts we had at hand. By the way, I thought CMS did a fantastic job with their report. It sounds like we are in agreement though, the nurse isn't the only cause of this completely preventable loss of life.
@@marcusmiller8270 Your analysis missed all of this:
ua-cam.com/video/VVWr_NKFonA/v-deo.html
Which proves my point that you can have the absolute best software available but without a skilled analyst using it, you’re still not going to do the victims and impacted parties justice.
Legislative changes? No... Education changes. I knew what vecuronium was and it's used only for induction and only with a stable airway the day I started working intensive care. She ignored the transport standard of care, a standard never forgotten, ever! Lol. No patient leaves any ICU without a bag valve mask and a portable monitor, EVER! To administer versed, coincidentally both are needed to monitor and protect the patients airway... Theses necessary items could have been used to avert the patients anoxic brain injury. Versed or vecuronium. Dosent matter. The standards of care were ignored and this idiot nurse got caught with her pants down. It's not a drug error, it's a incompetence error. A sentinel event! these occurrences are always prosecuted. These two fools presenting this crap are focusing on the wrong thing. The standard of care was ignored!
The difference between the other nurses that had been overriding medications and Radonda is they looked at the medication they pulled.
I’m sorry but I figured what was wrong without a graph.
Do you honestly need a policy in place to remember to look at a medication when you pull a medication from the pyxis. Stop overcomplicating it. Had Radonda done that alone, the patient would still likely be here.
The system didn’t fail Radonda…Radonda failed the system by failing to meet the bare minimum standards of care for nursing. Don’t believe me go blindly pull a medication from the pyxis and give it without looking at the vial. Not going to do it, wonder why?
Stop passing blame to further your own narrative.
Want to avoid this situation again? Look at your medications no matter if you are a nurse, paramedic, respiratory therapist, and even physicians.
Still not convinced that Vanderbilt is to blame
Thank you!
@CCRider Checking the label puts a lot of strain on a human under duress to do so. If the administration hadn't made overriding standard practice, then the incident could have been avoided. Those stops-those safeguards-are there as a buffer to prevent mistakes. For example, my car makes an annoying noise when I need to fasten my seatbelt. As a driver, it is quite common to be in a hurry and forget to put on the seatbelt. Suppose the manufacturer removed the audible sound and flashing light in the dashboard, and I am ejected from my vehicle post-accident. Wouldn't you think the incessantly annoying sound would have reminded me to buckle up? Aren't safety features the responsibility of the manufacturer? If they remove the standard practices to ensure safety, the manufacturer is to blame.
Simple! For younger generations. DONT TAKE NURSING COURSE just maybe of high pay salary or your jealous because they're wearing white uniform, or just because of your family tell you to become a Nurse.. BELIEVE ME BOOKS AND ACTUAL WORK IN HOSPITAL IS DIFFERENT. You can't SAY STOP for admitting patient to admission personnel because your tired enough to take care of 15 patients. You can't complaint because your a nurse and you need to take care of them because no one will do.
I understand what you mean, Joe. For example. CV-19 did not help one bit in the overload for nurses providing patient care. When conditions are extreme, mistakes are bound to happen. I wholeheartedly believe the hospital administration failed RaDonda. She asked the right questions, but the safeguards were not in place-if they had been, this fatal mistake could have been avoided. Unfortunately, most changes are only made after a significant loss.
I agree that many should take ownership in this mess, but she failed the fundamentals here. We’re talking stuff you learn on day one in school.. the stuff to cover your ass so that the “system” doesn’t crucify you. I wholeheartedly disagree that the system failed her entirely. In the end it was her responsibility to not cause harm (especially since it wasn’t her patient), yet she made an unfortunately tragic and incompetent error.
At 1:00-ummm, she did not do all that she could do. Systems are designed to help us prevent errors. They don’t replace good judgment. Either she didn’t know that Vec wasn’t Versed or she flat didn’t check the vial. There were overrides and warnings. No scanner in radiology? Still responsible for checking the vial. Furthermore, the fact that a scanner wasn’t available is even more reason for a double check.
That system wasn’t designed to prevent errors. It was obviously unsuccessful. You’re basically saying nothing else matters except what RV did. In which case what’s the point of everything else? If she’s responsible for it 100%, then she shouldn’t HAVE to use any of these systems to do her job.
@@EndoExcision I’m saying they systems are designed to help, but they are to be used in conjunction with nursing judgement. And two things can be true at the same time. The hospital was wrong and so was she. She didn’t check the vial. That’s just bare basic nursing. You should always make sure the med is correct.
@@4everyoung24 I would say the systems are not only designed to help, they should be designed to catch the errors people make. Yes, human error certainly occurred but we can't expect people to perform perfectly 100% of the time. She did lose her license over her mistakes which I think was fair. But putting her in jail shows me that no consideration was given that the systems that were supposed to catch her errors failed the patient as well. An effective RCA and impactful corrective actions that lead to system improvement would decrease the risk of future harm because of human error. Continuous improvement over time.
@@marcusmiller8270 she bypassed the systems on purpose to make her job easier. She hit override a multitude of times. So if she is bypassing the system before the system has any opportunity to work or be effective, is it really the systems fault. They recognized there would be a potential problem while transitioning to a new pharmacy software or pyxis software. Again others were overriding yes but I would guess they also looked at the VIAL!!!!!!!! Does Vanderbilt deserve some punishment for how they handled the situation after the patient death, yes but they didn’t cause the patient to die.
@@dklintworth1992 One of the root causes we identified was "Corrective Actions Need Improvement". The corrective action they used to overcome the problems with the electronic records and ADC was to remove an incredibly important safeguard, the override. Do you believe that is a safe decision by management? They basically made the last line of defense a person and no person is 100% perfect 100% of the time. That might be okay for issues with little consequence, but not for something as important as ensuring nurses don't pull the wrong medication.
One nurse and ONLY one nurse killed Charlene Murphey. Radonda Vaught! Her egregious "errors", TEN in all, were so far below the standard of care and ultimately causing the death of her victim, she deserves the criminal charges and conviction of her PEERS that she got. I hope the judge throws the book at her when she is sentenced.
I love your sense of compassion for others!
@@ronhoward2165 I have compassion for Radonda Vaught's VICTIM, Charlene Murphey.
Honestly this case proves why I don't trust medical personnel in the US. I used to work as a ED and OR nurse in Switzerland and I must say already the fact that nurses here have no clue what kind of medications a pyxis contains is just horrendous! In Switzerland you have to know every single medication you are using on your patients. The override function isn't the problem! That is in emergency cases a very important and necessary function. The only problem here was the nurse on the first place, she pulls a medication out of the pyxis never looking at it, never double checked it and then the worst and most shocking in this is that she went and administered the drug without the obligatory safety check which you must have learned in every nursing school! Namely; the right patient, the right drug, the right dose, the right route and the right time! So she failed on so many levels. Even if she would have administered the right drug I find it weird that the patient wasn't required to be monitored. Versed is a sedative and can cause respiratory depression. Obviously this hospital does not practice the monitoring as a standard under the effect of Versed. I only learned it the way that the patient should be monitored after administering Versed.
Sorry this is well-meaning but based on more inaccuracies than I have time to address. Here is a compilation of as much trial footage and related commentary that I could find. Vanderbilt really screwed up *after the fact* but she showed stunning ignorance and hubris. Her admitting that doesn’t bring Charlene Murphy back. Let’s do better AND improve systems and safeguards. ua-cam.com/play/PLzjkacgKi2KKH6RVU8L50oDbYcYhgZYm3.html
This is the only systematic review of the error. Everyone else is just spouting opinion. Stunning is an opinion. What series of events and errors and workarounds would be less stunning in THIS case? Not in general. In THIS case?
She made a mistake. That’s on her. But you’re arguing that none of the other safety systems matter.
Hindsight is 20/20. She thought the computer gave her the right medication. If she thought she had the wrong medication, I’m sure she would have asked. It is because medications have 2 different names, so she might have assumed it was the brand/generic names.
Medications should not have 2 names anymore.
Medication dispensing machine should not have auto populate. It is also easy to click on wrong medication when a list comes up.
Wrong… there are resources at ANYONE’S disposal to research any and all medications. That argument may have carried some weight before the ready availability of the internet.
If you can’t distinguish between the generic or trade name on a system that gives you the option of using both, then maybe the issue is not the system, but you.
@@dklintworth1992 I’m not a nurse and I don’t administer medications. As a doctor, I prescribe them, and I think it is time for us to use 1 drug name. It is easier to make mistakes if we use 2 metric systems for example.
@@hleangod most people do use the Brand name when talking by word of mouth. Most of the public say they take for example Zofran, Keppra, Synthroid, or Tylenol and not Ondansetron, Levetiracetam, Levothyroxine, or Acetaminophen. However nurses and even paramedics should not only know the Trade name, but the Generic. Also the pyxis station allows someone to search by either trade name or generic name.
Again this individual nurse cut corners by rushing herself in a NON-emergent situation and did not go through the 5 Rights of Medication Administration, did not verify the order with pharmacy despite the order being approved in the pyxis, she held onto the vial of medication for approximately 5-10 minutes before even administering the medication and not once looked at the vial until she was confronted about the error by the patient’s assigned nurse.
I would advise against defending such incompetence if I were you. If this error happened to your patient, despite clear and concise med orders then you would probably feel different.
@@hleangod You could pull the proper drug at the wrong strength and it is still a medication error. That should be obvious if you are a physician.
I hate that meds have 2 names.
These are well meaning people but this type of RCA is almost useless and does not get anywhere a real "root cause." Lots of such tools exist and they are useless and misleading.
Have you ever been trained in this technique? You might be surprised at what you find.
@@Mark1TN Yes, I've used dozens that are almost the same as this one. They are all the same. They assume that accidents are caused by chains of failure events. They aren't. That is oversimplified. And they omit the most important systemic factors like the role of management decisions and techniques to identify the problems BEFORE people are killed. Waiting and fixing each error found when it occurs is the reason that upwards of 400,000 people are killed by medical errors each year in the U.S. And it has been getting worse, not better. I know the people who practice RCA are well meaning. They are just contributing to the problem of blaming the low-level people (like nurses and technicians) and not getting at the real system design issues.
@@ngleveson I'm sorry that you have tried other RCA tools but they are not all alike. Perhaps someday you will attend a TapRooT RCA Course and then you will understand the difference.
@@ngleveson I believe you would be amazed by our system based on your comments. If you'd like a demo to truly understand how our methodology and RCA tools work to eliminate blame and bias, I'll be happy to set it up and listen to your thoughts after you have seen it.
Warning! This is sad. They are using this case as a sales tool. There are making statements such as "she was suppose to override". But earlier he stated policy was use override for emergency situation. This was not an emergency. There was so much about this video that was not helpful.
Yes, this case is a perfect example of why organizations need a standardized process to identify and eliminate problems found during audits or investigations so every identified problem leads to continuous improvement. It will save lives. I'm sorry I confused you. The override is typically only to be used in emergent situations. But to overcome a networking communication issue between the medical record and the cabinets, the temporary corrective action was to use the override until the communication problem was fixed. It was the easiest way to get the medication when orders and approvals couldn't get to the cabinets in a timely manner. So the safeguard was eliminated because of another problem.
And there it is - the sales pitch
Disgraceful
She hit the wrong med and she had properly looked up the drug she would have stopped then. If you don't recognize the drug you don't just give it! You can call pharmacy if you need to and they will explain the order. Pharmacy can call any MD and clarify the order also. I am sorry for everyone involved but especially the patient. The patient comes first.
Hindsight is 20/20. She thought the computer gave her the right medication. If she thought she had the wrong medication, I’m sure she would have asked. It is because medications have 2 different names, so she might have assumed it was the brand/generic names.
@@hleangod would have asked but she didn’t. She didn’t even look at the vial. Now ask 30 nurses if they would ever administer a medication without it having a label on it.
For more about TapRooT® RCA Training, see: www.taproot.com/solutions/rootcausetraining/
The CMS report can be found here: hospitalwatchdog.org/wp-content/uploads/VANDERBILT-CMS-PDF.pdf I see some comments are focused on blame. Do you think telling the people who make mistakes to "pay better attention" or you'll be fired or put in jail is a corrective action that will prevent this type of mistake from happening again? Will punishment help improve the 200,000 to 400,000 cases of harm each year by well-meaning but overwhelmed caregivers working in weak systems? Or do you think the punishment of honest mistakes is an easy way out that prevents innovation in finding ways to support the caregivers who dedicate their lives to helping others? Everyone will come to work one day bored, distracted, or overwhelmed and will make a mistake. Expecting people to be perfect 100% of the time is never a good idea. Focus on the systems. And in the report, you'll read about the broken and failed systems that were supposed to help recognize and catch this mistake. It's so easy to blame and to pretend we could never make the same mistake, isn't it?
This type of mistake is nothing new, the consequences of making this mistake haven’t changed, and furthermore this mistake cost someone their life because someone couldn’t take the time to comprehend 2 words “paralyzing agent”.
So now tell me, if Jail time is too harsh… what should happen. Now ask yourself how would that justice feel to you if that was your mother in the scanner that lied there motionless and was conscious the entire time and feel like you are suffocating and you can’t even blink your eyes to alert anyone that you need help.
I am not saying that I am free from mistakes, however I know for a fact that I have enough integrity to look at every vial of medicine I intend to administer.