This is what happened…..
A nurse, Rodonda Vaught, filling a loosely defined role of ‘help-all nurse’ was asked by a Neuro Intensive Care Unit nurse to go to Radiology and give a patient Versed for anxiety prior to a PET scan.
She mistakenly took Vecuronium, otherwise known as Norcuron, instead of Versed, and gave an undetermined amount to the patient and then went about her next tasks which were in the Emergency Room. Norcuron and other drugs in its class are powerful paralytics used mostly as an adjunct to anesthesia and occasionally when a patient has life-threatening bronchospasms. It is similar to the ‘active’ ingredient in poison arrows used in the Amazon.
Approximately 30 minutes after the order was given, the patient was found to be without a pulse and not breathing. A code ensued and a heart rate was established and the patient, now being mechanically ventilated, was taken to the Neuro ICU.
After the patient was returned to the Neuro Intensive Care Unit, the nurse who made the error went to the patient’s room. The physician, a Nurse Practitioner and a couple of residents were all at the bedside. She explained her error and the team of doctors and residents were then able to understand what had happened to the patient.
The following day, the patient was extubated and died ten minutes later. Within a few more days, Vaught was terminated.
Surprisingly, all of this happened at the prestigious Vanderbilt University Medical Center Hospital.
Fast forward eleven months. State surveyors entered the hospital for a complaint survey. It seems unlikely that the state of Tennessee sat on this complaint for eleven months prior to the survey but who knows? The survey resulted in a scathing survey report that included an ‘Immediate Jeopardy’ tag. It included interviews with the nurse who made the error, the radiology personnel and multiple hospital executives. My notes are on the survey report attached to the link.
Shortly after the survey, Vaught was indicted for reckless homicide and patient neglect.
As noted, Vaught took full responsibility for her error when it happened. This is in stark contrast to the behavior of Vanderbilt’s leadership. This is a quote from the survey by Vaught (RN#1):
I was asked if it was documented he/she had administered the Vecuronium in Patient #1’s medical record. RN #1 stated, “I did not. I spoke with [Named Nurse Manager] and he/she told me the new system would capture it on the MAR [Medication Administration Record]. I asked and [the Nurse Manager] said it would show up in a special area in a different color.
In other words, they told her NOT to chart the error. I disagree with that advice. I would not use words like ‘error’ or ‘major catastrophe’ or even the acronym, ‘OMG’, but the med should have been charted.
She was then asked if she talked to anyone in the days following her medication error. Really? That was Vanderbilt’s focus. Who knows about this?
Vanderbilt had a policy and a list of high risk medications that included Vecuronium (Norcuron) which would have been relevant had the nurse knew that was what she had given. Even so, the policy did not have any procedures in place for monitoring after the administration of a high risk medication.
Vanderbilt overlooked numerous reporting responsibilities after terminating the nurse. Management seemed to mostly forget about the incident. The information reported to the coroner’s office was incorrect. No medication error was reported as required.
In fact, Ms. Vaught has a license that is current and free of disciplinary action. Nevermind that the Tennessee state board of nursing mandates reporting unsafe practice and unsafe practice conditions to recognized legal authorities and to the Board where appropriate. I would hope that a patient death met that standard.
When asked why the event was not reported, the Senior Quality and Patient Advisor and the Regulatory Officer could not provide an answer and deferred the question to Risk Management. The Senior Quality and Patient Advisor later reported back to the surveyors that Risk Management had provided the following response:
I talked to Risk Management about reporting to the state, and [he/she] stated we [Risk Management] follow the 2009 state rules on reporting and it includes abuse, any, exploitation, fire with disruption of service, strikes, external disasters, misappropriation and injury of a patient in a nursing home of unknown nature. [He/She] said for you to see the state regs,[regulations], page 31, 6d.
I had to read that several times to ensure that I understood it. Apparently, the Risk Manager couldn’t be bothered to meet with the surveyors and instead told them to read the regs. Those regulations can be found here.
The Director of Patient Safety told the surveyors: ‘In the end, there were so many things the nurse did – the 5 rights, basic nursing care’. The Director of Patient Safety had a very narrow scope of vision.
Nobody can argue that the nurse gravely and egregiously erred and as a result of her mistake, a patient died. But there is a flip side to this coin. Nurses who inadvertently harm patients are the second victim of medication errors. Please read the linked article. Apparently, many people are sympathetic to Ms. Vaught. A GoFundMe campaign to pay for her legal support has collected 43k in three days.
But, Ms. Vaught was not the only one who made a grave and egregious mistake. Vanderbilt came out of the gate with flawed judgment. If all of the factors contributing to this event were investigated instead of limiting the scope to pointing fingers, both nurses and patients would enjoy a safer environment. It’s not much in light of a patient death but it would be something.
Instead, Vanderbilt leadership failed to report the incident or implement a plan of corrections that included nursing education about high risk medications and use of the Automatic Medication dispenser. They did not reeducate the nurse who made the error. They seem to be okay with a nurse dispatching another RN who has no experience with a patient to give conscious sedation. Seriously, who thought a ‘help-all’ nurse was a good idea?
Vanderbilt Hospital has very low scores on Medicare reported outcomes. Is this because the Vanderbilt way of addressing problems is sweeping them under the rug? Or, did they choose to ignore the reporting requirements because they were aiming for Medicare Stars. Inquiring minds want to know.
Every nurse needs to be held accountable for their mistakes. It is painful but growth comes from pain. Being indicted on homicide charges? That’s too much. What do you think?