Posted on Mar 22, 2022
As a nurse faces prison for a deadly error, her colleagues worry: Could I be next?
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https://www.npr.org/sections/health-shots/2022/03/22/ [login to see] /as-a-nurse-faces-prison-for-a-deadly-error-her-colleagues-worry-could-i-be-next
Four years ago, inside the most prestigious hospital in Tennessee, nurse RaDonda Vaught withdrew a vial from an electronic medication cabinet, administered the drug to a patient, and somehow overlooked signs of a terrible and deadly mistake.
The patient was supposed to get Versed, a sedative intended to calm her before being scanned in a large, MRI-like machine. But Vaught accidentally grabbed vecuronium, a powerful paralyzer, which stopped the patient's breathing and left her brain-dead before the error was discovered.
Vaught, 38, admitted her mistake at a Tennessee Board of Nursing hearing last year, saying she became "complacent" in her job and "distracted" by a trainee while operating the computerized medication cabinet. She did not shirk responsibility for the error, but she said the blame was not hers alone.
"I know the reason this patient is no longer here is because of me," Vaught said, starting to cry. "There won't ever be a day that goes by that I don't think about what I did."
Four years ago, inside the most prestigious hospital in Tennessee, nurse RaDonda Vaught withdrew a vial from an electronic medication cabinet, administered the drug to a patient, and somehow overlooked signs of a terrible and deadly mistake.
The patient was supposed to get Versed, a sedative intended to calm her before being scanned in a large, MRI-like machine. But Vaught accidentally grabbed vecuronium, a powerful paralyzer, which stopped the patient's breathing and left her brain-dead before the error was discovered.
Vaught, 38, admitted her mistake at a Tennessee Board of Nursing hearing last year, saying she became "complacent" in her job and "distracted" by a trainee while operating the computerized medication cabinet. She did not shirk responsibility for the error, but she said the blame was not hers alone.
"I know the reason this patient is no longer here is because of me," Vaught said, starting to cry. "There won't ever be a day that goes by that I don't think about what I did."
As a nurse faces prison for a deadly error, her colleagues worry: Could I be next?
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I have multiple questions on this case. 1. What unit was this this nurse and patient in? If this was not an ICU with ventilators or Anesthesia, why was Vecuronium in the drug cabinet? 2. What hour of the shift of this nurse did this incident happen? It has been shown in many studies, error go up exponentially after yhe 10th hour. 3. Why was this computerized med cabinet not programmed for 5 letters?.
In my career, I never dealt with one of these type med cabinets, I did try to get my last hospital to purchase an anesthesia cart with one. The cost was prohibitive.
The drug this nurse injected by mistake, should realistically only be kept by anesthesia or in a ICU unit where patients are on ventilators. The fact that this drug needs to be reconstituted, should have been a clue to the nurse, but with all things considered, I believe there are more things at play here.
In my career, I never dealt with one of these type med cabinets, I did try to get my last hospital to purchase an anesthesia cart with one. The cost was prohibitive.
The drug this nurse injected by mistake, should realistically only be kept by anesthesia or in a ICU unit where patients are on ventilators. The fact that this drug needs to be reconstituted, should have been a clue to the nurse, but with all things considered, I believe there are more things at play here.
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Maj Robert Thornton
LTC David Brown there are numerous things that still puzzle me regarding the article. Yes, she failed the 5 rights of medication admin. But, how long has she been a nurse? How many hours had she worked? What was her patient load? Was this during the Covid crunch where nurses were working ridiculous hours? Why was Vecuronium even in her drug dispenser if not in anesthesia?
I have more questions than that even.
Yes, she is negligent, I am having a hard time understanding she is being prosecuted. Too many questions.
I have more questions than that even.
Yes, she is negligent, I am having a hard time understanding she is being prosecuted. Too many questions.
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MSG Thomas Currie
"Yes, she is negligent, I am having a hard time understanding she is being prosecuted." Perhaps because negligent homicide is also called manslaughter -- and under either name it is a felony in every state in the US (and probably in every country in the world). You don't get to say ''Oops, my bad'' as an excuse when you kill someone, especially when the negligence is severe enough to be considered gross indifference.
People are prosecuted every day for various cased of "accidental" homicide - many involving far less clear negligence.
So, your "Yes, she is negligent" also means "Yes she is guilty" -- those other questions that come to mind are mitigating factors, but they don't change the basic fact that she had a responsibility and was grossly negligent.
People are prosecuted every day for various cased of "accidental" homicide - many involving far less clear negligence.
So, your "Yes, she is negligent" also means "Yes she is guilty" -- those other questions that come to mind are mitigating factors, but they don't change the basic fact that she had a responsibility and was grossly negligent.
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Maj Robert Thornton
MSG Thomas Currie I understand where you are coming from, but these cases are usually settled with license revocation and malpractice payouts. It is very rare to see a criminal case, unless it is a pattern.
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MSG Thomas Currie
Maj Robert Thornton - That was in the days when hospitals were able to stonewall and coverup cases of gross negligence easily. The next of kin either never learned that hospital personnel made a mistake at all, or they settled for whatever the hospital's insurance company was willing to pay because it was extraordinarily difficult to get anyone in the medical INDUSTRY to testify against anyone else in the medical industry.
Only the very most obvious cases could ever go to criminal court because it was (and still is) nearly impossible to achieve "beyond a reasonable doubt" with a jury of laymen when there is almost always some doctor somewhere who can be paid to testify that whatever the accused did wasn't unreasonable or at least obfuscate the negligence behind a cloud of medical terms. This case is going to court because of the combination of modern publicity, public horror, and the difficulty of the defense trying to find any doctor or nurse who would swear that they might have done the same series of multiple gross errors.
Only the very most obvious cases could ever go to criminal court because it was (and still is) nearly impossible to achieve "beyond a reasonable doubt" with a jury of laymen when there is almost always some doctor somewhere who can be paid to testify that whatever the accused did wasn't unreasonable or at least obfuscate the negligence behind a cloud of medical terms. This case is going to court because of the combination of modern publicity, public horror, and the difficulty of the defense trying to find any doctor or nurse who would swear that they might have done the same series of multiple gross errors.
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Over decades nurses by far are the most respected professionals. And in my psychology courses, they perform at esceptional levels.
Rich
Rich
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If it was not intentional you have to look at her work load and hours when this took place. Suspension & termination would be proper instead of jail time. Jail time does nothing to rehabilitate and can make things worse. It will not help bring back the patient.
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MSG Thomas Currie
Jail time won't bring back the patient. Should we do away with jail for other homicide cases because it won't bring back the deceased?
Jail time does nothing to rehabilitate. Should we do away with jail for all other crimes because most criminals go on to commit more crimes, so obviously jail didn't rehabilitate them?
Jail is one of the consequences of committing a crime. Regardless of whether the state calls it "negligent homicide" or "manslaughter" it is still the a crime when someone kills another person due to gross negligence amounting to an indifference to the risks. You're a light vehicle driver, presumably you know that you could go to jail if you kill someone in an "accident" where you are at fault.
If the person she killed was a member of your family would you think that telling her to go work at a different hospital was the reasonable outcome? Being tired or distracted is not justification for carelessness when you know that lives depend on your actions.
I don't recall all the details in this story as it was reported at the time, but I do recall that there were multiple mistakes made -- and yes multiple people made some of those mistakes -- but overall the responsibility and the failure rested with this nurse.
Jail time does nothing to rehabilitate. Should we do away with jail for all other crimes because most criminals go on to commit more crimes, so obviously jail didn't rehabilitate them?
Jail is one of the consequences of committing a crime. Regardless of whether the state calls it "negligent homicide" or "manslaughter" it is still the a crime when someone kills another person due to gross negligence amounting to an indifference to the risks. You're a light vehicle driver, presumably you know that you could go to jail if you kill someone in an "accident" where you are at fault.
If the person she killed was a member of your family would you think that telling her to go work at a different hospital was the reasonable outcome? Being tired or distracted is not justification for carelessness when you know that lives depend on your actions.
I don't recall all the details in this story as it was reported at the time, but I do recall that there were multiple mistakes made -- and yes multiple people made some of those mistakes -- but overall the responsibility and the failure rested with this nurse.
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