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That case goes far beyond med error and I don't understand why people keep bringing it up as an example. She pulled the wrong med, and then injected it and wal

That case goes far beyond med error and I don't understand why people keep bringing it up as an example. She pulled the wrong med, and then injected it and walked out of the room rather than observing for effects. Also the med she pulled had warnings on all sides of the bottle and on the top saying very clearly that it's fatal to administer without ventilation. This went beyond a mistake to negligence.

cyberlurker 4y ago
Right, when I first read the summary it didn’t adequately cover how careless the nurse was. It wasn’t just a small mistake. Edit: I should say that doesn’t mean I think it makes any sense the hospital isn’t liable and jail time for the nurse seems odd
sithlord 4y ago
Literally every medication has warnings slapped all over it. My partner worked at Vanderbilt (on a different floor) around this time, and one constant complaint I heard (prior to the incident) was how there was hardly any controls around anything there.
- ikiris 4y ago
  Yeah, there's no doubt that this is a shitshow from how Vandy is described (and nursing in general especially with these automated pharm boxes), but that should be additional consequences, not this nurse avoiding hers.
- JshWright 4y ago
  Every medication does not have a bright red cap with a bold warning printed on the top (that you have to look at at least twice while reconstituting and then drawing up the med). The warnings on a vial of Vecuronium go well beyond the typical "This medication may case XYZ side effect", and for very good reason.
rvba 4y ago
> She pulled the wrong med, and then injected it and walked out of the room rather than observing for effects With staff shortages nurses dont have the time for that. Hire 2x more nurses - so there is 2x more time for each patient.
- Master_Odin 4y ago
  My GF is a nurse and I've heard her talk about working a number of 12 hour shifts and not having the ability to go to the bathroom, get water, or have lunch, all because of how strapped the unit is and arduous the requirement is to do these things (usually having to leave the unit). I'm honestly shocked we're not hearing more mistakes, and it should be 100% hospital admins on the chopping block for forcing these insane work environments upon nurses while expecting quality patient care.
js2 4y ago
Janie Harvey Garner, a St. Louis registered nurse: “In response to a story like this one, there are two kinds of nurses,” Garner said. “You have the nurses who assume they would never make a mistake like that, and usually it’s because they don’t realize they could. And the second kind are the ones who know this could happen, any day, no matter how careful they are. This could be me. I could be RaDonda.” https://khn.org/news/article/radonda-vaught-nurse-error-medication-dispenser-homicide-trial-tennessee/ https://khn.org/news/article/radonda-vaught-nurse-error-medi... HN readers can look at this case filing: https://www.documentcloud.org/documents/6785652-RaDonda-Vaught-DA-Discovery https://www.documentcloud.org/documents/6785652-RaDonda-Vaug... > Also the med she pulled had warnings on all sides of the bottle and on the top saying very clearly that it's fatal to administer without ventilation. The linked PDF includes images of medicine in question. There's a single warning on top that reads "WARNING: PARALYZING AGENT" and a red cap. I don't see any warnings on the side. The vial appears to be tiny, smaller than my thumb. But yes, she made a series of mistakes, listed on the last two pages of the PDF. I am not a nurse, but I can easily imagine how someone could make the errors she did in an overworked and high-stress environment. It's a cascading series of errors that starts with overriding the medicine cabinet when she can't find the medicine she's looking for. But according to her defense, overriding the cabinet had become almost standard operating procedure at Vanderbilt at that timeframe. Once she starts down this path, she's operating on automatic and almost blind to what she's doing. I agree she was negligent. I don't think she should go to prison for it. In the bigger picture, this is causing more nurses to quit, likely leading to more medical errors and deaths, not fewer.
- ikiris 4y ago
  If nurses quit over criminal liability for killing someone by being that careless, everyone is better off by them not being in the field. Pharmacy has had the same rules for over a hundred years. A great example is even in the movie a wonderful life. edit: minor grammar fix
- gruez 4y ago
  >I agree she was negligent. I don't think she should go to prison for it. but we literally have a law for "negligent homicide"?
bsder 4y ago
The hospital that hires the nurse should be responsible for the nurse. Period. Under all circumstances. The hospital has far too many incentives to play fast and loose and then leave the nurses in the lurch with a system stacked against them. The hospital has far too many incentives to skimp on training and safety. etc. Should this nurse also have her license looked into? Yeah, it looks like it. And is it up to the hospital to fire her or not? Yes. However, barring actual proof of premeditation, all charges and fines should land on the hospital--not the nurse.
BeFlatXIII 4y ago
People like you are part of the problem. "It was covered in all kinds of scary warning labels"—just like every other medication in that drawer. Medical professionals are totally blind to alerts given off by their EMRs because everything has a password-protected warning so that the audit logs can say "yes, this physician/nurse read and understood the warning"
- JshWright 4y ago
  > just like every other medication in that drawer No, very different from every other med in the drawer. The red cap on the vial is very unusual (reserved for very dangerous meds like this), and the bold printed warning on the top (that you have to look at at least twice while while preparing to administer this medication) is also something used very rarely.

cyberlurker 4y ago

Right, when I first read the summary it didn’t adequately cover how careless the nurse was. It wasn’t just a small mistake. Edit: I should say that doesn’t mean I think it makes any sense the hospital isn’t liable and jail time for the nurse seems odd

sithlord 4y ago

Literally every medication has warnings slapped all over it. My partner worked at Vanderbilt (on a different floor) around this time, and one constant complaint I heard (prior to the incident) was how there was hardly any controls around anything there.

ikiris 4y ago
Yeah, there's no doubt that this is a shitshow from how Vandy is described (and nursing in general especially with these automated pharm boxes), but that should be additional consequences, not this nurse avoiding hers.
JshWright 4y ago
Every medication does not have a bright red cap with a bold warning printed on the top (that you have to look at at least twice while reconstituting and then drawing up the med). The warnings on a vial of Vecuronium go well beyond the typical "This medication may case XYZ side effect", and for very good reason.

rvba 4y ago

> She pulled the wrong med, and then injected it and walked out of the room rather than observing for effects With staff shortages nurses dont have the time for that. Hire 2x more nurses - so there is 2x more time for each patient.

Master_Odin 4y ago
My GF is a nurse and I've heard her talk about working a number of 12 hour shifts and not having the ability to go to the bathroom, get water, or have lunch, all because of how strapped the unit is and arduous the requirement is to do these things (usually having to leave the unit). I'm honestly shocked we're not hearing more mistakes, and it should be 100% hospital admins on the chopping block for forcing these insane work environments upon nurses while expecting quality patient care.

js2 4y ago

Janie Harvey Garner, a St. Louis registered nurse: “In response to a story like this one, there are two kinds of nurses,” Garner said. “You have the nurses who assume they would never make a mistake like that, and usually it’s because they don’t realize they could. And the second kind are the ones who know this could happen, any day, no matter how careful they are. This could be me. I could be RaDonda.” https://khn.org/news/article/radonda-vaught-nurse-error-medication-dispenser-homicide-trial-tennessee/ https://khn.org/news/article/radonda-vaught-nurse-error-medi... HN readers can look at this case filing: https://www.documentcloud.org/documents/6785652-RaDonda-Vaught-DA-Discovery https://www.documentcloud.org/documents/6785652-RaDonda-Vaug... > Also the med she pulled had warnings on all sides of the bottle and on the top saying very clearly that it's fatal to administer without ventilation. The linked PDF includes images of medicine in question. There's a single warning on top that reads "WARNING: PARALYZING AGENT" and a red cap. I don't see any warnings on the side. The vial appears to be tiny, smaller than my thumb. But yes, she made a series of mistakes, listed on the last two pages of the PDF. I am not a nurse, but I can easily imagine how someone could make the errors she did in an overworked and high-stress environment. It's a cascading series of errors that starts with overriding the medicine cabinet when she can't find the medicine she's looking for. But according to her defense, overriding the cabinet had become almost standard operating procedure at Vanderbilt at that timeframe. Once she starts down this path, she's operating on automatic and almost blind to what she's doing. I agree she was negligent. I don't think she should go to prison for it. In the bigger picture, this is causing more nurses to quit, likely leading to more medical errors and deaths, not fewer.

ikiris 4y ago
If nurses quit over criminal liability for killing someone by being that careless, everyone is better off by them not being in the field. Pharmacy has had the same rules for over a hundred years. A great example is even in the movie a wonderful life. edit: minor grammar fix
gruez 4y ago
>I agree she was negligent. I don't think she should go to prison for it. but we literally have a law for "negligent homicide"?

bsder 4y ago

The hospital that hires the nurse should be responsible for the nurse. Period. Under all circumstances. The hospital has far too many incentives to play fast and loose and then leave the nurses in the lurch with a system stacked against them. The hospital has far too many incentives to skimp on training and safety. etc. Should this nurse also have her license looked into? Yeah, it looks like it. And is it up to the hospital to fire her or not? Yes. However, barring actual proof of premeditation, all charges and fines should land on the hospital--not the nurse.

BeFlatXIII 4y ago

People like you are part of the problem. "It was covered in all kinds of scary warning labels"—just like every other medication in that drawer. Medical professionals are totally blind to alerts given off by their EMRs because everything has a password-protected warning so that the audit logs can say "yes, this physician/nurse read and understood the warning"

JshWright 4y ago
> just like every other medication in that drawer No, very different from every other med in the drawer. The red cap on the vial is very unusual (reserved for very dangerous meds like this), and the bold printed warning on the top (that you have to look at at least twice while while preparing to administer this medication) is also something used very rarely.