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Posted on 03/28/2022 4:24:36 PM PDT by nickcarraway
Healthcare workers fearful of repercussions from former nurse RaDonda Vaught's conviction
, Director of Enterprise & Investigative Reporting, MedPage Today
Healthcare workers are alarmed by the conviction of former Nashville nurse RaDonda Vaught, who now faces prison time over a medical error.
"We could all and probably have been close to this situation because we're continuously stretched too thin," Kelsey Fassold, RN, an ICU nurse, said in a LinkedIn post. "We try so hard to do the best by our patients while the odds are stacked against us."
Jeremy Faust, MD, MedPage Today's editor-in-chief, said in an Inside Medicine post that the verdict "may contribute to a culture of silence around medical errors."
"Such silence may make systemic problems less readily identified and rectified. This is the opposite of what we need," Faust wrote. "We need to destigmatize human errors, acknowledge them, and learn from them."
On Friday, Vaught was convicted of negligent homicide and gross neglect of an impaired adult, after she allegedly gave 75-year-old Charlene Murphey the paralytic vecuronium when she was meant to give her the anti-anxiety drug Versed. Vaught had been acquitted of a reckless homicide charge.
Vaught faces 1 to 2 years in prison for the negligent homicide charge, and 3 to 6 years on the gross neglect charge, according to Kaiser Health News. Her sentencing is scheduled for May 13.
Typically, serious medical errors are handled by licensing boards or civil courts -- not prosecutors.
The American Nurses Association said in a statement that the "criminalization of medical errors could have a chilling effect on reporting and process improvement."
"ANA supports a full and confidential peer review process in which errors can be examined and system improvements and corrective action plans can be established," the statement said. "Transparent, just, and timely reporting mechanisms of medical errors without the fear of criminalization preserve safe patient care environments."
Faust said that during his career, he witnessed a very similar error. Instead of confusing vecuronium with Versed, Faust said a nurse gave the paralytic rocuronium when she was meant to give the antibiotic Rocephin.
"Fortunately, the mistake was immediately recognized, and the patient suffered no immediate or long-term consequences," Faust wrote. "In fact, the patient was informed as to what was happening in real time, given a play-by-play narration of what had just happened and what would happen next," which included giving Sugammadex to reverse the effects of rocuronium.
"The nurse who made the mistake was experienced, respected, and every bit as caring as the very best healthcare colleagues I have worked with over the years," Faust wrote. "In other words, this was not some green, distracted, or emotionally detached bad apple. In my mind, all of that added up to one thing: this could have happened to anyone."
"If honest errors lead to criminal convictions, every incentive will be to sweep things under the rug," Faust added. "If we don't learn from both our successes and our failures, things will get worse, not better."
Fassold noted in her LinkedIn post that she considered Vaught's mistake a "systemic error" and that "when something bad happened, the nurse took the heat."
"Nurses are constantly put in unsafe and harmful conditions that can and will hurt patients. Not because they're not trying, but because they're working themselves to death trying to keep up with what the system demands from them," she wrote -- a sentiment that has echoed throughout the nursing world as it struggled to provide care through the COVID-19 pandemic.
"Nursing ratios are far worse now than they ever have been," she continued. "How many more situations will occur just like this? It's time nurses stand up for themselves, their license, and their life. It's time nurses say no to unsafe assignments. It's time nurses tell administration that what [they're] demanding is unsafe and harmful. It's time we all stand together and demand change."
Vanderbilt University Medical Center, Vaught's former employer when the error occurred, said via an email from a spokesperson that it did not have a comment on the verdict.
What she did was worse than what the Police did when georgy Floyd died. If you can’t read the label, get glasses. Be VERY VERY careful when administering meds. She wasn’t, someone died. Why shouldn’t she get some jail time?
Howzabout you hire her to look after your dementia-stricken parent or Downs Syndrome child.
Code of Hammurabi territory here.
I’ve read that more people are killed by medical mistakes than any other cause. A medical accident is no accident. Like the man said. Buy Glasses.
Medical mistakes are definitely in the top three causes of death/illness, IMHO. I do have some experience in this.
These are the same people who demanded police lock people up glfor covid.
Its far more complicated than this.
She was floating in an unfamiliar area. she had a student assigned to her (distracting). When given the order to use the machine to dispense the medicine
Sorry, partial post. Continuing. When given the order, she went to use one of the machines, it didnt work. Went to a superior who told her that yeah, the machines not working is a known thing, try a different one. The patient is in the ER, so the time pressure is building up. Went to a different machine, that one didn’t work. Asked a superior, was told to over-ride the error which allowed her to use a shorter keyword to get the wrong machine. After she gave the med, she was called out to a different area. She asked the radiology department to have someone monitor the patient, but was told the patient would be OK, no go to where you’re told. Patient was left unmonitored and died.
So yes, ultimately she gave the wrong medicine, but it was a series of events in a well meaning person, in which a series of errors including the machines at the hospital and other staff’s attitudes has some culpability as well.
Can read quite well, thanks. Bad medical outcomes occur through different, and often multiple, missteps, and often by multiple individuals. Civil liability is one thing, and criminal prosecution is entirely another. Unless you’re talking about “Angel of Death” psychopaths who deliberately administer lethal medications, criminal prosecution is a good way to end up with no physician or nurse to take care of you in your old age.
Wouldn’t the pharmacy hold some responsibility for dispensing the wrong medication? I am not sure but wouldn’t the first step be verifying the right medication is given out for correct patient?
Never mind. I just read the medication was dispensed from a electronic medication cabinet. I would not be shocked to discover such cabinets have lead to other such errors. All nicely swept under a rug.
Thanks for the explanation.
People who want to criminalize this kind of accident are clueless about the inherent weakness of humans. Humans are not flawless machines. We have malpractice laws and lawsuits for errors and omissions… Much of the progress that has been made in improving patient safety has come because of non-punitive approaches to error identification and reporting. An entire science has developed around improving patient safety by honest, competent professionals. Perfect clinicians do not exist, no matter how much we want them to be 100% perfect and eternally flawless. Patient safety will be worsened by criminalizing accidents in this manner.
Well, I suspect you know the maxim, “Doctors bury their mistakes”, is hardly a novel truism.
I would not be shocked to discover such cabinets have lead to other such errors.
Even worse was the infamous Therac 25.
https://tildesites.bowdoin.edu/~allen/courses/cs260/readings/therac.pdf
There already is a culture of silence about medical mistakes. This nurse should never have been convicted.
Vecuronium or Versed? Rocuronium or Rocephin? A reading problem by people taught to read using modern methods instead of phonics?
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