INDICTED!
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?
Homicide? I don’t get it. Nurse documented and reported. Should have set in motion Risk Management and Event Investigation. Nurse put on leave until matter resolved. Reported to authorities once the patient was pronounced and autopsy ordered. Right?
I believe she was fired shortly after but regardless, that’s what happened. Homicide! I am stunned. Here’s something. The nurses at Novus Hospice who deliberately killed patients got charged with fraud and got a one year sentence.
I do have sympathy for this nurse. I am, however, in agreement with negligent or reckless homicide. No. She is not a criminal, but as Julienne stated, the nurse “egregiously erred and as a result of her mistake, a patient died.” Even if she had given Versed as ordered, she just “walked away” to go do something else in the ER? She overrode in the Pyxis to get a medication that started with “Ve” and oh, here it is. We’re not talking about Ativan here. Did she intend harm? No. She reported her mistake and I’m sure she is heartbroken over this. But, and I’m not a lawyer, but I believe her actions qualify for “negligent” homicide. Should she go to prison? No. Not everyone who is charged with negligent homicide goes to jail. A friend of mine got drunk and hit and killed another person. He was critically injured. He got probation; never drove again and never drank again. His life started anew. He visited nursing homes and shut ins, started going to church, and became a new person. Was it the possibility of going to prison or the 6 week coma and a come to Jesus meeting? Not sure. But he said he had an experience in that coma.
And I hope the money collected for her gives her a good defense lawyer who will plead that her self-reporting the error and her sincere distress over the incident will get her probation and maybe some community service. I think she should self surrender her license and take some courses to improve her critical thinking skills and knowledge of dangerous drugs. THEN, the powers that be should turn their full attention to the ridiculous inattention of Vanderbilt Hospital to safety and safe-guards. My hospital’s Pyxis does not even have Vercuronium or Versed. These dangerous drugs are kept in locked boxes, not in a Pyxis. Can just anyone override? There are a select few at my hospital who can override. I worked in a small hospital but our safe-guards are much more selective and appropriate. (I’m retired.) The hospital should take a major part of the responsibility for this horrendous blunder.
If someone gets drunk and runs a stop-sign and hits your best friend, should he/she be charged with negligent/reckless homicide? Yes. Did this person intend to do harm? No. But someone is dead and is dead because of slowed reflexes, impaired vision, or whatever you call it…..negligence. The nurse was not impaired, but she was still negligent; gave the wrong medication (even if it was the Versed, she shouldn’t have left) and someone who shouldn’t be is dead. I also heard that the family doesn’t want charges brought. I’m not sure I would be so generous. I could forgive, but I am pretty sure I would want justice for my loved one.
I agree with much of what you said. I’m. It a lawyer either but was wondering about malpractice as opposed to criminal charges.
As I see it, we have all made mistakes. I have made the exact same mistake – giving a patient the wrong meds. Nothing bad happened. Nobody died. I was in nursing school and was surprised by how kind everyone was. As time went by, I realized the doctor and my instructor had all done the same thing. I have never made the same mistake again.
It’s the same with your drunk driving example. There are people who have a little to drink and drive home with no problem. Then there are those who hurt people. It is devastating to everyone involved.
I’m not sure you can separate the nurse’s actions from Vanderbilt’s. The Drug dispenser (like a pills PEZ), in my opinion should not have had Vecuronium in it.
But it doesn’t matter because Versed required monitoring (and does not require reconstitution). The nurse did not know her drugs. The vecuronium had a red ring through which she inserted the needle. That troubles me that she could be in such a hurry that she overlooked it.
So Ms. Vaught is not innocent but I’m not sure she will ever get a job again with a homicide conviction. What’s the goal? Improve healthcare or ‘make her pay’? Background checks are not just for healthcare.
I wonder why the Pill PEZ dispensers don’t have basic drug monographs that are spit our especially with overrides?
So many questions. I feel bad for everyone involved.
The blog needs to be short. This one was longer than most but it could have been three times longer. But please read that linked article about second victims. Nurses have actually committed suicide after fatal drug errors.
Long day. I feel certain that this Vanderbilt event could be rewritten as a Greek Tragedy.
When any error occurs in the course of administering care to a patient, the question,”Do I have to fill out an incident report? should never be asked.
Unfortunately this seems to be a common “practice” nowadays.
Many other factors need to be examined staffing ratios, use of Temporary services , floating to other units with no training in the care of the specialty…
Prayers for the nurse and the family involved in this tragedy.
Thank you for sharing, Julianne.
Dianne, I wholeheartedly agree with you. Incident reports should not be viewed as punitive. A patient may take all the wrong meds and that would be an incident in home health but there seems to be a resistance to writing up events unless they happened in front of the nurse, It’s like, if it wasn’t witnessed, it didn’t happen.
The limited views of the Vanderbilt leadership are of concern. There is already one tragedy involving a patient death. If those issues you brought up are not addressed, there will be more. It also took place during the holidays which always means just a little more chaos.
You see this more and more. Health care workers who make an error are being charged criminally. It is crazy. Unless there is criminal intent, it should be a matter for the board of nursing, and perhaps a malpractice issue. But criminal charges? It is a wonder anyone wants to go into healthcare now. They are making it impossible. We are not allowed to be human, to need breaks, to have limits. Something like this should be a never event, but it is understandable. In the heat of the moment she thought the med was the same by the sound of the name. What she did was make a grave mistake, but there was no criminal intent. If she was unsure about the name similarity she should have taken a moment to find out. My heart goes out to both the nurse and the family.
You are correct in that it should be a matter for the board or maybe a civil suit but before that, it should have been a concern for Vanderbilt. I lay awake wondering who reported it and why the nurse alone is being held accountable.
Nurses who have endangered lives by taking drugs at work don’t face criminal charges. They are supported by their peers and to a degree, the board. Nurses who call out on holidays leaving the rest of the staff short pose a huge danger to patient safety. They don’t face charges.
A doctor once told me, in jest, to call him if I needed him but to remember need is a sign of weakness. It’s kind of funny but also describes a pervasive attitude in healthcare. But if you are truly strong, you ask for help. And you say No when to giving drugs you don’t know. You don’t just follow orders blindly because you’re afraid to cause ‘drama’. We all learn that eventually and I’m certain that Ms Vaught would have, too.
We shudder when we consider the near misses in our past. We should appreciate them because there but for the grace of God it could have been us.
my thoughts are the facility and it’s administrators are just as responsible as that nurse. Because nurses are people as well and are apt to make mistakes if given the wrong tools. However I do believe that a nurse just like a doctor is held at a high standard. I would never give a medication unless I done my rights. And I would never give a medicine but I didn’t know what the side effects or the effects would be. Short staffed or running out of time that patient could have been my family member or my patient could be your family member. I’m sorry this happened to that patient and that patients family. I am sorry that happened to that nurse and that nurses family. But tools can cause mistakes ask not used appropriately and updated often. Just thinking
You are correct. I would not use a table saw balanced on three legs even if they were cheaper. But I would spend the extra money for a table saw that prevented accidents especially if I had employees using it.
There is much we don’t know but I think that the only way I would stand behind charging the nurse would be if the hospital took every possible measure and the nurse aimed to intentionally hurt someone.