Nurse convicted of negligent homicide

[VA77]

I know this isn't pharmacy but does touch several aspects of healthcare professionals and wanted to post to get some feedback. Hoping some of you in the hospital world can comment on how you feel about this and how technology/human error/etc. played a role. It's hard for me to judge cause I'm in the retail world and been out of this arena for a while but honestly leaves a bad taste in my mouth for charging someone with negligent homicide. Reminds me of the Eric Cropp case in OH.

Former nurse found guilty in accidental injection death of 75-year-old patient

RaDonda Vaught's conviction could lead to years in prison. It's a rare case of a medical mistake being deemed a crime, and many worry it will have a chilling effect on the entire nursing profession.

www.npr.org

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[Rockinacoustic]

As a pharmacist in the ED/Crit Care setting I recognize my bias in the obvious fact that Vec needs to be reconstituted and midazoalm doesn't. Both come as 1mg/mL so depending on the dose of Versed for MRI (5 mg would be a lot) that's easy to miss.

But, if they override a bar code scan It's hard to disagree there was negligence.

 

[Sparda29]

Don't search by brand names. If she had typed in Midazolam this wouldn't have happened.

From the pharmacy side, the informatics team should make sure that brand names do not show up at all in the drug library and that if someone searches based on the brand name that no result comes up.

 

[Seriously Serious]

Does she deserve to be charged for negligent homicide? Idk, probably not. If she wasn't charged, I think some could ask what kind of example would this set? It's a tough one man.

 

[confettiflyer]

Don't search by brand names. If she had typed in Midazolam this wouldn't have happened.

From the pharmacy side, the informatics team should make sure that brand names do not show up at all in the drug library and that if someone searches based on the brand name that no result comes up.

That sounds like a one way trip to 51,249,786 EHR feature request tickets for brand names.

 

[lord999]

I do not have a particular issue with the license revocation. There is precedent for this, even from accidents. I do have an issue with negligent homicide as a chilling effect, but it does have a major standard to meet which is not what we would think ourselves. I do expect that we will "learn" from this not to self-incriminate ourselves.

 

[PharmDBro2017]

That sounds like a one way trip to 51,249,786 EHR feature request tickets for brand names.

You can just go into Omnicenter, search the drug you want, and remove the alias of the brand name. Takes 15-30 sec per item.

From what I had read the ADCs had been on critical override for a while and she was very used to doing overrides on a daily basis, unfortunately. She was also a floater from a different floor and unfamiliar with what she was doing.

I agree that vec requires reconstitution and that SHOULD have made her pause and think. Either way a tragic outcome and the fact that Vandy tried to sweep it under the rug makes it worse. Punishment on the nurse is too severe, and there's not enough punishment on Vandy admin for NOT creating a Just Culture.

 

[VA77]

So many things bad on this but I think the 1 thing to me is how you handle a mistake when it happens which I applaud the nurse for and should be an example of Just Culture.

Vanderbilt U. My God! They settled with the family less than 2 weeks since the incident and had 2 doctors sign off of the death certificate that the patient died from natural causes and didn't report incident to state or federal officials until CMS specifically asked for a report. Everybody makes mistakes but it certainly looks like they did everything they could to keep it a secret and this to me is the definition of culpable.

I also agree that NOBODY is going to be reporting errors and this will be another prime example of "Say nothing, see nothing, hear nothing".

 

[sfachine]

Makes you think how many are never brought to light.

 

[sdh0202]

I felt bad about the whole situation although I agree with this RN's negligence.. this shouldn't have been charged as a criminal case. My wife is in nursing school and this is apparently a hot topic for them too so I went onto RN subreddit trying to understand their point of view. There was one post mentioning about this trial but somehow it turned into exposing all pharmacy's mistake they caught and bitching about pharmacy's negligence. We understand that all human makes mistake and somehow they think they are the only short-staffed and we have to remain perfect? As a solo night rph who covers 300+ beds hospital, I hope they understand that your melatonin or diaper rash cream is not a priority when there are critical/trauma patients in ICU/ED and the amount of med returns from the floor we bring back to pharmacy in daily basis is ridiculous too lol

 

[mentos]

I agree the punishment is too severe. Think of all the criminals who got a slap on the wrist for doing much worse things.

 

[gwarm01]

Did the vecuronium vials have a paralytic agent sticker attached? That's a quick visual aid to help with this situation.

 

[allantois]

And this is a reminder that you will be judged by an average Joe than a jury of your peers

 

[Rockinacoustic]

Someone posted this on the Anesthesiology sub-forum:

DocumentCloud

www.documentcloud.org

Pages 5 and 6 shed light on some of the events leading to the error.

 

[BenJammin]

The lesson that can be learned from this is to never talk to the government about your med errors even if you're required to by law.

 

[alpha12]

The lesson that can be learned from this is to never talk to the government about your med errors even if you're required to by law.

Pull a deshaun Watson and plead the fifth to every question.

 

[ValeRx]

Where was the outcry for pharmacists when Eric Cropp was burned at the stake for a med error? Oh they didn't care because it wasn't a nurse. Now they're all up in arms.

 

[confettiflyer]

Thanks Nashville/Davidson County District Attorney and TN (and Ohio)… I wonder how many med errors will be unreported, hidden, or obfuscated.

My advice to everyone in these backwards jurisdictions (or anywhere, really) is to never ever admit fault, never apologize, and never make it easy for any investigation (though you should minimally cooperate to maintain legal compliance). Don’t volunteer any extra information, don’t conduct internal investigations over discoverable means, know your state’s evidence codes (1157 in California).

These lawyers and career prosecutors don’t care about med safety, just notches on their belts and re-election. Nice job, a-holes.

 

[confettiflyer]

Did the vecuronium vials have a paralytic agent sticker attached? That's a quick visual aid to help with this situation.

It would actually cover the “Caution: Paralytic Agent” warning that’s baked onto the cap of the vial.

If you put it on the vial, you could cover name/barcode.

If you flag it, you set yourself up for error because if the RNs are primed to see flags, and it falls off, they may assume it’s not a paralytic.

 

[NITRAS]

Did the vecuronium vials have a paralytic agent sticker attached? That's a quick visual aid to help with this situation.

Brought to you by: I googled it cause I was curious too.

 

[rxkrafted]

Pure negligence. I would normally try to show her some sympathy but she bypassed way too many safety nets. Sure nurses override meds all the time from the ADC in the OR area but they always try to scan the med to make sure it's on the MAR since they bypassed the first safety measure. I occasionally get a call when a med doesn't scan and I find out that they are holding a different medication upon inspection.

 

[George Lincoln]

I know this isn't pharmacy but does touch several aspects of healthcare professionals and wanted to post to get some feedback. Hoping some of you in the hospital world can comment on how you feel about this and how technology/human error/etc. played a role. It's hard for me to judge cause I'm in the retail world and been out of this arena for a while but honestly leaves a bad taste in my mouth for charging someone with negligent homicide. Reminds me of the Eric Cropp case in OH.

Former nurse found guilty in accidental injection death of 75-year-old patient

RaDonda Vaught's conviction could lead to years in prison. It's a rare case of a medical mistake being deemed a crime, and many worry it will have a chilling effect on the entire nursing profession.

www.npr.org

Yep terrible mistake but I see other people around me making mistakes but their responsibility is pretty much nonexistent. First we have to realize that we are human not Gods. As a surgeon I consistently reviewed my complication rates. Mine were always below national averages but they were not zero. Could I advertise like a car company and boast about my JD Power report, of course the answer is no.
We are expected to be infallible yet we are all human one of the most important things to be considered when we treat our fellow humans. All reading understand that and if you don’t your in the wrong place. That being said the public needs to understand this as well.
There was a similar case a number of years ago with a famous actors child getting the wrong dose of heparin multiple times. In that case he recognized why there was confusion and suggested changing bottle size and labels for the different concentrations.
In the referenced case here there was an allegation of distraction. In my office one thing we had to do to reduce distraction was to make it policy that no one had their cell phone on their person. The problem was that employees were constantly being bombarded with texts that were superfluous. For all they were told that we were going old school. If someone had to contact them about something important call the office and the receptionist would put the call through.
Bottom line is to eliminate distractions. Like when my new vehicle went in for its first service the tech never put the oil filler cap on and I blew out all the oil. What was he thing about, God only knows; but the company had to give me a new vehicle.
The topic of errors needs to be examined in it’s totality, not with knee jerk reaction.

 

[PharmerInPNW]

Someone posted this on the Anesthesiology sub-forum:

DocumentCloud

www.documentcloud.org

Pages 5 and 6 shed light on some of the events leading to the error.

I find page 49 and 50 equally as interesting.

 

[mustang sally]

I have mixed feelings on this one, but making it a criminal case seems a bit much to me. Loss of licensure seems more appropriate.

Also seems hard to believe that the hospital has zero liability in this...why not go after the hospital as well or instead of the nurse?

Edited to add: after reading pg 50, it does seem a little more damning on the RN.

 

[BidingMyTime]

It was a horrific mistake, and yes the nurse really screwed up, but no, I do not think healthcare professionals should be criminally charged for honest mistakes, even if highly incompetent, mistakes. Long ago it was realized that covering up mistakes in healthcare benefits no one, and leads to the proliferation of more mistakes. Mistakes should be encourage, and required to be documented.....1) so ways to prevent frequent mistakes can be made (ie tall man letters, requiring premix KCL, better computer alerts or labeling) and 2) requiring remediation or firing incompetent workers. If people are scared that they or their co-workers are going to prison for honest mistakes, than this will have a chilling effect on mistake documentation.

And this is a reminder that you will be judged by an average Joe than a jury of your peers

Which is a reason to consider asking for a bench trial......haha, a lawyer friend told me to get a bench trial if you are innocent (or if the facts are on your side) and go with the jury trial if you are guilty (or if the facts aren't on your side.)

Where was the outcry for pharmacists when Eric Cropp was burned at the stake for a med error? Oh they didn't care because it wasn't a nurse. Now they're all up in arms.

What the? There was a ton of outcry about Eric Cropp when that happened, both on this board and others. The OP here even mentioned Eric Cropp!

 

[ValeRx]

What the? There was a ton of outcry about Eric Cropp when that happened, both on this board and others. The OP here even mentioned Eric Cropp!

I'm not talking about what the OP said.

 

[BidingMyTime]

I'm not talking about what the OP said.

Then what were you talking about? On studentdoctor, there was a huge outcry about Eric Cropp. Also on pharmacy blogs and magazines and other boards. Where were you/what space are you talking about, where everybody ignored what was happening with Eric Cropp?

 

[Sunshine98*]

Window is open. All it takes is a change of state law.

 

[allantois]

Window is open. All it takes is a change of state law.

Predatory lawyers will never let that happen

 

[awval999]

I believe there are situations so egregious so outside the scope of medical practice that criminal prosecution is warranted. This case merits the criminal charges.

I believe this is no different than when police officers act so outside the scope of their practice that they are criminally charged.

 

[alpha12]

I believe there are situations so egregious so outside the scope of medical practice that criminal prosecution is warranted. This case merits the criminal charges.

I believe this is no different than when police officers act so outside the scope of their practice that they are criminally charged.

Even then they get a light sentence. Kim potter only got two years for manslaughter

 

[confettiflyer]

I believe there are situations so egregious so outside the scope of medical practice that criminal prosecution is warranted. This case merits the criminal charges.

I believe this is no different than when police officers act so outside the scope of their practice that they are criminally charged.

It was absolutely egregious, she pretty much bypassed every possible safety measure that exists…but I can’t ignore the down line effects.

Nothing will bring this patient back, but how many more patients will now die because healthcare workers will be less willing (even if it’s just a smidge) to be forthright and forthcoming? How many will look at a 75 year old victim and just hope they don’t conduct an autopsy?

How many pharmacists and technicians buried minor IV compounding errors after the Eric Cropp case? I think it’s > 0, and that’s scarier.

 

[owlegrad]

I believe there are situations so egregious so outside the scope of medical practice that criminal prosecution is warranted. This case merits the criminal charges.

I believe this is no different than when police officers act so outside the scope of their practice that they are criminally charged.

This is a good point but police officers acting so far outside their “scope of practice” that they are criminally charged isn’t exactly comparable to medical errors imo. Then again I am obviously biased.

If we are comparable to police officers can we get qualified immunity as well please?

 

[alpha12]

If we are comparable to police officers can we get qualified immunity as well please?

I think some countries do something similar to that where you can’t sue doctors.

 

[Dred Pirate]

It was absolutely egregious, she pretty much bypassed every possible safety measure that exists…but I can’t ignore the down line effects.

Nothing will bring this patient back, but how many more patients will now die because healthcare workers will be less willing (even if it’s just a smidge) to be forthright and forthcoming? How many will look at a 75 year old victim and just hope they don’t conduct an autopsy?

How many pharmacists and technicians buried minor IV compounding errors after the Eric Cropp case? I think it’s > 0, and that’s scarier.

I have always been a champion of patient safety and "just culture". I report of a lot of errors/near misses not because I want to get anyone in trouble (heck, I have reported myself), but because when I see a systemic problems, I want to fix them so they don't happen again. Of we identify ways errors happen, we can then address it. Covering it up doesn't do anybody any good. Although I do now see this type of case causing people to be more likely to try to cover their tracks.

 

[VA77]

Just in case you wondered what happened.

Tennessee nurse convicted in lethal drug error sentenced to three years probation

RaDonda Vaught's prosecution was widely condemned by nurses, who said it set a dangerous precedent that would worsen the nursing shortage and make them less forthcoming about admitting mistakes.

www.npr.org

 

[KidPharmD]

Just in case you wondered what happened.

Tennessee nurse convicted in lethal drug error sentenced to three years probation

RaDonda Vaught's prosecution was widely condemned by nurses, who said it set a dangerous precedent that would worsen the nursing shortage and make them less forthcoming about admitting mistakes.

www.npr.org

I think the sentence (probation with the possibility of expunging her record) is proof that this wasn't ever intended to be justice but grandstanding by the local DA.

 

[TranslationalRPh]

I think the sentence (probation with the possibility of expunging her record) is proof that this wasn't ever intended to be justice but grandstanding by the local DA.

Didn't the judge decide the sentence not the ADA or juror. Also, doesn't this make it easier for any civil suits now too? Not sure if that has already been done, but if not, it seems like it would be a slam dunk given the lower legal standard.

 

[KidPharmD]

Didn't the judge decide the sentence not the ADA or juror. Also, doesn't this make it easier for any civil suits now too? Not sure if that has already been done, but if not, it seems like it would be a slam dunk given the lower legal standard.

The family has previously said they had no desire to sue her. The DA is the one who made the decision to charge her in the first place. The state also never asked for a greater punishment than probation. The judge could have given her the maximum, but no one was asking him to (except the husband apparently).

 

[TranslationalRPh]

The family has previously said they had no desire to sue her. The DA is the one who made the decision to charge her in the first place. The state also never asked for a greater punishment than probation. The judge could have given her the maximum, but no one was asking him to (except the husband apparently).

I'm not as familiar with the backstory.

Given that her husband "wanted Vaught to receive 'the maximum sentence,'" I wouldn't be surprised if he does go after her civilly, health permitting, provided that the statutes of limitations is not up. With a conviction on the books, I suspect it wouldn't be very difficult because of the lower standard. He understandably is grieving hard and now harbors clear animus towards her. I definitely think judicial discretion was warranted in this case. I also believe that the state ADA has a compelling interest establishing successful prosecution in criminal negligence for many reasons, including as a deterrent towards future misconduct. I once heard a fictional prosecutor say, just having the conviction on the books means that the next person put into situation may think twice. I don't know if it's true, but it seems reasonable to me.

 

[lord999]

I think the sentence (probation with the possibility of expunging her record) is proof that this wasn't ever intended to be justice but grandstanding by the local DA.

And the judge probably took that into consideration as well as the victim's family wishes. That said, if the sentence was egregious, I would expect it to be thrown out on appeal as this case lacks malice aforethought or dishonesty on the nurse's part.

I don't the precedent of a conviction for a honest and honestly reported mistake. 'Every nurse should never override, patients be damned' is the conclusion I would take from this experience.

I do support the license revocation though, certain mistakes, even if honest, have consequences in terms of should never be in practice again.

The quieter issue is the problem that I expect this to have a chilling effect on reporting, and knowing my colleagues' stories at Vanderbilt, it's already taken effect as well as tanking management relations. It's definitely spread to Tenneesee Valley.

 

[KidPharmD]

And the judge probably took that into consideration as well as the victim's family wishes. That said, if the sentence was egregious, I would expect it to be thrown out on appeal as this case lacks malice aforethought or dishonesty on the nurse's part.

I don't the precedent of a conviction for a honest and honestly reported mistake. 'Every nurse should never override, patients be damned' is the conclusion I would take from this experience.

I do support the license revocation though, certain mistakes, even if honest, have consequences in terms of should never be in practice again.

The quieter issue is the problem that I expect this to have a chilling effect on reporting, and knowing my colleagues' stories at Vanderbilt, it's already taken effect as well as tanking management relations. It's definitely spread to Tenneesee Valley.

Both of these things have happened here. We have had several reports of nurses refusing to override medications, instead choosing to be even more persistent in coming to ask us to verify meds. The number of nurses I have had coming to ask me to verify things that have literally just been put in has probably quadrupled. I think we will also see a significant decreases in our global overrides as well (maybe that's not so bad).

We have also not had a single self reported error in the time since the trial started. That is extremely unusual for us. I feel like I watched 5 years of teaching our nurses that reporting errors was essential for us to prevent them and not a "write up" just go up in smoke in the span of a couple of weeks.

 

[Dr Meow]

No one's going to bring up the systemic issue that Nurse doing any form of anesthesia or as Nurse Anesthetists shouldn't even be a thing and that they're just bootleg Anesthesiologists.
These midlevels are not qualified and they overstep their boundaries. Imagine if this was a physician? The entire field would be under fire.

 

[NITRAS]

No one's going to bring up the systemic issue that Nurse doing any form of anesthesia or as Nurse Anesthetists shouldn't even be a thing and that they're just bootleg Anesthesiologists.
These midlevels are not qualified and they overstep their boundaries. Imagine if this was a physician? The entire field would be under fire.

I’m not a fan of mid level encroachment, but this case has nothing to do with that. This is a nurse, acting in nursing role, doing nursing things who made a series of mistakes that unfortunately led to a patient’s death.

I think this should be a reminder that we work with dangerous drugs, and over-riding medications is actually a dangerous thing. We need to do it sometimes, but not nearly as often As we do.

 

[sadface]

I wish more hospitals had dedicated FTEs for Med safety. I imagine Vanderbilt is big enough for a full pharmacist FTE but I feel most small hospitals don’t give anyone dedicated time, it’s just a background expectation of all staff.

 

[allantois]

Plot twist: the prosecutors really just want to keep RN wages up by driving everyone away from the profession

 

[allantois]

No one's going to bring up the systemic issue that Nurse doing any form of anesthesia or as Nurse Anesthetists shouldn't even be a thing and that they're just bootleg Anesthesiologists.
These midlevels are not qualified and they overstep their boundaries. Imagine if this was a physician? The entire field would be under fire.

Ya think having less APPs is gonna result in LESS errors?

What does this even have to do with this case?

Physicians are gonna end up the only people in the hospital the way this is going

 

[RXDOC1986]

negligent homicide: def.:​

Hospital pharmacist for over 36yrs. Actual expert court witness in a law suite( paid $3000/day to state my name, credentials and say "yes"! )
There is no cross examination to credentials and facts!!!!
As my colleagues aptly pointed out, the med error is common, even sometimes escalated to Sentinel Event. Hundreds of thousands of inpatients are hurt or killed by med errors every year in the USA. What is key is overriding software safeguards that are designed to save lives.
I am always concerned with errors during my shift that might bring harm to a patient. So many moving parts before a medication makes it into a patient. Human error is +/- 5%, this is acceptable with 99.9% of the workforce, except in pharmacy. You cannot enter 100 orders and put through 5 absolute mistakes a day. You are expected to be 100% accurate, or you will be written up and fired within days.
We have EPIC at our hospital (I much prefer CERNER). There is a function key for all prescribers, to bypass serious allergy/drug interactions, and put their order through. It says "defer to R.Ph." and it absolves them of any malpractice. It says pharmacist will dig through the BS and fix it.

 

[quickpic007]

I know this isn't pharmacy but does touch several aspects of healthcare professionals and wanted to post to get some feedback. Hoping some of you in the hospital world can comment on how you feel about this and how technology/human error/etc. played a role. It's hard for me to judge cause I'm in the retail world and been out of this arena for a while but honestly leaves a bad taste in my mouth for charging someone with negligent homicide. Reminds me of the Eric Cropp case in OH.

Former nurse found guilty in accidental injection death of 75-year-old patient

RaDonda Vaught's conviction could lead to years in prison. It's a rare case of a medical mistake being deemed a crime, and many worry it will have a chilling effect on the entire nursing profession.

www.npr.org

Didnt Eric Cropp do 4 months in a county Jail for less negligence?
And other RNs and the patients family are almost celebrating this RN mistake?
Crazy!!

Anyone know what Eric Cropp is up to?

 

[owlegrad]

Didnt Eric Cropp do 4 months in a county Jail for less negligence?
And other RNs and the patients family are almost celebrating this RN mistake?
Crazy!!

Anyone know what Eric Cropp is up to?

Eric Cropp didn’t self report the error either, if we are pointing out differences between the cases.