Nurse charged with reckless homicide after giving vecuronium instead of Versed.

[Texas42]

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

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

www.tennessean.com

An interesting, and sad story.

In case you are curious, this is what the bottle looks like.

 

[ZX9RCAM]

Three years ago....

 

[Texas42]

Former Vanderbilt nurse RaDonda Vaught found guilty on 2 charges in 2017 death of patient

RaDonda Vaught was convicted of reckless homicide and impaired adult abuse in the death of Charlene Murphey at Vanderbilt University Medical Center.

www.usatoday.com

Sorry, her guilty verdic was just announced. I was trying to avoid USA today, didn’t realize it was an old article. It’s all over the medical forum I’m on.

 

[Fishkiller]

So sad. Too many people die on Hospitals due to medical mistakes, malpractice.

 

[cajunautoxer]

Former Vanderbilt nurse RaDonda Vaught found guilty on 2 charges in 2017 death of patient

RaDonda Vaught was convicted of reckless homicide and impaired adult abuse in the death of Charlene Murphey at Vanderbilt University Medical Center.

www.usatoday.com

Sorry, her guilty verdic was just announced. I was trying to avoid USA today, didn’t realize it was an old article. It’s all over the medical forum I’m on.

If you don't mind me asking. What medical forum are you member on.

 

[Axxe55]

Seems a bit heavy-handed for a mistake.

Maybe nurses should be carrying malpractice insurance like doctors carry.

 

[Texas42]

If you don't mind me asking. What medical forum are you member on.

SDN (student doctor network). I started when i was a student and stayed on.

Seems a bit heavy-handed for a mistake.

Maybe nurses should be carrying malpractice insurance like doctors carry.

Malpractice insurances doesn’t cover criminal hearings, and even then, malpractices doesn’t usually cover gross negligence.

The RN overrode multiple hard stops from the Pyxis machine, literally had to draw from a vial that says “Paralytic”, had to reconstitute it (which Versed does not). Then she left the patient unmonitored in a scanner for half an hour. Even if the patient got Versed, she still would require monitoring as it can cause apnea all by itself.

The last bit is probably the most damning. I’m on the fense about criminal charges, but it was pretty darn egregious. And that doesn’t even address the coverup by Vanderbilt and the nursing board.

 

[Axxe55]

SDN (student doctor network). I started when i was a student and stayed on.


Malpractice insurances doesn’t cover criminal hearings, and even then, malpractices doesn’t usually cover gross negligence.

The RN overrode multiple hard stops from the Pyxis machine, literally had to draw from a vial that says “Paralytic”, had to reconstitute it (which Versed does not). Then she left the patient unmonitored in a scanner for half an hour. Even if the patient got Versed, she still would require monitoring as it can cause apnea all by itself.

The last bit is probably the most damning. I’m on the fense about criminal charges, but it was pretty darn egregious. And that doesn’t even address the coverup by Vanderbilt and the nursing board.

Sounds like maybe they need tighter controls on the dispensing of medication if she could "over-ride" the controls. Maybe the dispensing system is to blame as well.

And that doesn’t even address the coverup by Vanderbilt and the nursing board.

I'm curious about this. Article stated they assisted in investigating the incident.

 

[innominate]

Sounds like maybe they need tighter controls on the dispensing of medication if she could "over-ride" the controls. Maybe the dispensing system is to blame as well.

And that doesn’t even address the coverup by Vanderbilt and the nursing board.

I'm curious about this. Article stated they assisted in investigating the incident.

The override isn't the problem. Certain areas need the override function. Certain things you need immediate access. You don't have time for a practitioner to input an order then wait for it to get approved by pharmacy.

I didn't read the article but I remember hearing about it when it happened. If what Texas42 said about having to reconstitute the drug is correct that is one of many flags that the nurse appears to have ignored. Steps that veer from routine should cause you to pause and assess.

 

[Axxe55]

The override isn't the problem. Certain areas need the override function. Certain things you need immediate access. You don't have time for a practitioner to input an order then wait for it to get approved by pharmacy.

I didn't read the article but I remember hearing about it when it happened. If what Texas42 said about having to reconstitute the drug is correct that is one of many flags that the nurse appears to have ignored. Steps that veer from routine should cause you to pause and assess.

I think from a standpoint of safety, any time that a system can be "over-rided" that there is something wrong with the system and a recipe for disaster.

I'm not familiar with the protocols f the medical field , but in the industrial field that there are procedures and protocols as to who and when an over-ride can take place, and those who would be held accountable if those over-rides take place and damages or injury result.

I fully agree with the second paragraph of your post though. Those should have been glaring red flags, that she did seem to ignore or disregard. But I also believe tighter controls on the system might have prevented this from happening in the first place.

It would surprise me in the least if new systems and protocols are not adopted because of this tragic death.

 

[mongoose]

Seems a bit heavy-handed for a mistake.

Maybe nurses should be carrying malpractice insurance like doctors carry.

My Mom did carry malpractice insurance when working as a RN in a "charge" nurse capacity.

 

[innominate]

The protocols of the machine are not the problem. When you work in certain areas you have access and the need for certain meds that are not the norm in other areas. A nurse from the floor can not access the Pyxis in my department that contains these meds. I actually do not need to override anything in our Pyxis. I have access to every med in our machine. In other departments I can override to gain access to all meds but those machine generally do not contain vecuronium. I don't know the nurse's explanation for what happened in this incident but she screwed the pooch.


Eta: In our department Vec and other meds generally used during intubation are kept in a locked refrigerated Pyxis. If I hear the fridge unlock I instinctively know I touched the wrong line on the screen if I'm trying to remove versed.

 

[BigTexasOne]

Recent studies of medical errors have estimated errors may account for as many as 251,000 deaths annually in the United States (U.S)., making medical errors the third leading cause of death

And yet, they want to ban "assault rifles" because approx 300 people per year die of being shot by a rifle, any kind! Maybe we should ban nurses, or hypodermic needles, or hospitals!

 

[DoubleDuty]

The override isn't the problem. Certain areas need the override function. Certain things you need immediate access. You don't have time for a practitioner to input an order then wait for it to get approved by pharmacy.

I didn't read the article but I remember hearing about it when it happened. If what Texas42 said about having to reconstitute the drug is correct that is one of many flags that the nurse appears to have ignored. Steps that veer from routine should cause you to pause and assess.

My wife was an RN for 45 years. She was always cautious when dispensing medicine. Double check everthing.

 

[Renegade]

"The nurse then typed the first two letters in the drug’s name – “VE” – into the cabinet computer and selected the first medicine suggested by the machine, not realizing it was vecuronium, not Versed"

Seems like more careless than reckless.

 

[TX OMFS]

I agree with the trial outcome. The worst thing she did was fail to monitor the patient. Even if she gave the correct Versed (midazolam), the standard of care is to monitor the patient. If she had been watching the pt interventions could have been made & the mistaken vecuronium would not have been fatal.

Sent from my SM-N986U1 using Tapatalk

 

[innominate]

"The nurse then typed the first two letters in the drug’s name – “VE” – into the cabinet computer and selected the first medicine suggested by the machine, not realizing it was vecuronium, not Versed"

Seems like more careless than reckless.

I can't speak for everyone but when I can't find a med on the first attempt I'm actually paying greater attention to the results on the screen on the following attempt. Some different meds can come in the same vial. I've even seen 2 cardiac meds that have opposite effects come in the exact same vial with the same colored label. One was white with blue letters and the other was blue with white letters. The pharmacy actually kept those in the exact same drawer pocket. In my opinion that was just asking for a human error mistake. I told pharmacy it was bad idea but pharmacists don't think like normal people. In this case a vial of versed looks different than a vial of vec. Even if you chose the incorrect med on the screen you would notice when the drawer opened. And like others have stated, the patient's ekg, o2 sat and bp are suppose to be monitored when administering conscious sedation. The error did not have to be fatal.

Some nurses at work are upset over the ruling.

 

[Vaquero]

Probably had a phone in one hand.
Distracted.

**** that.

 

[Tnhawk]

So sad. Too many people die on Hospitals due to medical mistakes, malpractice.

Doctors bury their mistakes.

 

[msharley]

So sad. Too many people die on Hospitals due to medical mistakes, malpractice.

500,000/yr............or more...."medical misadventure"....