Nurse RaDonda Vaught Convicted of Homicide? A Doctor Explains
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- čas přidán 5. 09. 2024
- Yeah, this is bad. Here are my thoughts from a Facebook live episode I did when the verdict came back and released initially for subscribing Supporters on CZcams.
Here are my prior shows on Nurse RaDonda Vaught's case: zdoggmd.com/?s...
Join us on Locals for exclusive live shows and group discussions: zdoggmd.locals...
This is just my humble opinion as an RN for 22 years. I would never, ever, ever recommend that anyone become an RN, because it sucks! The helping people part, that all nurses go into it for is all but gone. It's all paperwork, computer screens, subervience, running on maximum for the entire shift, no breaks, not even to pee. Cannot recommend. This is just so sad.
Could not agree more. Former RN here...
I agree. It now takes me twice as long to process half as many patients because I spend massive amounts of time jumping through the computer hoops and talking to IT.
23 year nursing career here. Working for terrible management, manager. assistant manager and director. Mean girls club. Only care about productivity for their bonuses. They could care less how short staffed we are. I wish I could leave nursing, but can't afford to.
I am returning to nursing after a 6 month sabbatical. I've been in this field for 42 years and just needed a break. I miss it. Kinda sorta.
I was really getting excited about going back and now this happened.......
I'm not going back to the bedside though. I'm actually going into County Correctional Health so that'll be different. I hope I like it. I was very adamant during my interview but I absolutely will not work above my scope or my licenses. I will not work in an unsafe or toxic (within reason) environment.
BTW. The County has really good benefits. That's another reason why I'm willing to give it a try. If it turns out to be just like every other Healthcare job, than I'm just going to retire.
But yeah, Monkey Town USA, I don't encourage people to go into the field of nursing anymore. Especially the ones that are just looking at it as a "good career" because they'll hate every day of their life.
My nurse friends say the same. It boggles my mind when they say the work 10 or 12 hours and cannot take a minute to pee. I get pissed abd tell them there are labor laws. That is illegal. You have to by law take breaks. Yall..just go pee for the love of god.
never seen a doctor defend a nurse before, thank you
Our son's neurosurgeon verbally slapped his resident for making a nurse cry. She was correct in her observation also the residents ego just couldn't handle it
Hahahaha. Sooo true!
Been a nurse for 16 years. I'm on my way out. I'm going into software development. I actively discourage people from becoming nurses. The workload is inhuman. Employers will offer you up for sacrifice in a heartbeat. No matter how hard you try, nothing is ever good enough. It sucks. Now being vulnerable to criminal charges for not being able to keep up with a workload that no human can do and to be held to a level of perfection that is virtually impossible is nothing more than throwing your life away deliberately to be set up for failure.
So correct...the system does not care about nurses nor any other health care workers for that matter (talk to pharmacist) it is about numbers and money. So you know that means do not care about patients either.
@@ccirish4519 I'm loving the bootcamp I'm in. It's like solving puzzles with logical creativity. It's awesome!
This is what nursing has become. I can’t even be happy for new nurses anymore.
It needs to change. They need assistants to do the necessary computer and paperwork. They shouldn't be forced to work insane hours. They'll be more unnecessary deaths because of exhaustion!
I'm on my 16th year as an OR Nurse. I am looking to move to non-clinical nursing which I wish to happen soon. Congrats to you.
As a nurse thank you for taking a stand for us. Unfortunately we are going to have a huge problem in the future of nursing because there wont be enough of them.
True the rewards don't outweigh the risks
This story is why I left the bedside. There were so many situations, daily, that sound just like this when I worked in a hospital. Being a hospital nurse is the highest stakes, highest stress job. Nurses are the people executing every order that is placed and the only true patient advocate at the same time. We are charged with the safety of each person and required to put them at risk with every order we carry out. Thank you for sharing this!
And you did the right thing. But the people who stay and don’t fight the system or make it known to the public that were in danger aren’t doing anyone any favors.
I agree! Now imagine every move and conversation being recorded and you understand the stress of a police officer!
@@m.m4982 We do. Hospital floors now have cameras
@@deanagallatin6974 I know they generally have them in hallways but do they have them in every patient room? They record audio?
@@erselley9017 somethings wrong with you. No I'm not a police officer! I just know they have the most difficult job in the world and their every move is scrutinized and politicized. Even if I was a police officer (and I assure you I'm not) why would you address me as if I was the very person that arrested someone. That's the thing, police officers aren't responsible for what some other random officers do, just like all nurses are not responsible for what some bad ones out there do. That kind of response is rooted in ideology not far from what racists do. You seem to Judge people based on whole groups, I'll let you figure out what that's called. Your response is REALLY out there though. Get some therapy, sounds like you need to talk to someone! Good luck!
Retired RN after 39 years. Unbelievably difficult profession. Why would a nurse have access to this type of medication in radiology?
If they need to emergently intubate while in radiology, or if they have an already intubated patient that needs the medication so they don't pull out the ETT.
It was taken from the neuro step-down unit's Pyxis and taken to the patient in radiology.
Thats what i want to know...this biggles my mind
@@konnihall9671 so another nurse pulled the med, and gave it to the radiology person? That’s an issue
@@1packatak no the nurse gave the medication to the patient, she did not gave it to radiology person, radiologists techs do not push meds. Anytime you give patient medications to calm them down especially if it is IV push meds, you’re supposed to stay there and monitor the patient but she didn’t do that. Source - Im an icu nurse.
The fact that Vanderbilt tried to hide this shows you that this nurse is just being made an example of to cover up for the fallacies of their entire institution 💯
I guess you watched this already. I was going to share it to you.
@@bronna01 yes, and this is why I did the video I did the other day, did you see it?
@@jovoorheescollinsmphbsnbch6245 yes!
Oh yeah. Big systems protecting other big systems while scapegoating the actual workers
I wonder if those folks lost their jobs or were charged as well!
Amen to Vanderbilt having trouble recruiting nurses. As a nurse of 38 years I am so disappointed in the changes in healthcare and how we are able to care for patients. Every nurse has or will make an error, fortunately most do not cause harm. God bless RaDonda Vaught
Yes Lynn, "but for the grace of God go I"
is a humbling lesson we all must understand before we can effectively be there for others...nurse of 48 years has not been easy
Amen!
Error vs reckless and negligent
I’m an LPN graduating with my RN in May, and the only place my school has promoted the entire time is a hospital for work. Well, I have worked 16 yrs in a rehab setting, and on a respiratory unit, and I can’t tell you how many times upon admissions I have found WTF errors. Not just nurses, but MD errors as well! I received patients from the hospital who NEVER should have been discharged in the first place,and I had to turn around and send them back to the hospital!Our healthcare system is broken, and the nurses are being used as scapegoats! Watch a mass exodus of nurses in the next few years!
The outflow of nursing is reported to already be near 20%/year. Soon there will be no one left to take care of the patients.....
The boomers are retiring and countless don’t want to go this path(Nursing) or take on the student loan debt while being treated like $hit. The staffing shortage just keeps growing and growing…. To counter this hospitals will just increase the RN/Patient ratio🤦♂️
Yep, my neighbor is a nurse having just graduated three years ago. Already having enormous amounts of stress from attempting to look after 15 patients a day. After the news came out that RaDonda was convicted she is now starting a new career as a Recruiting Agent working for a large Employment agency. Four to five years of education and enormous tuition fees voluntarily flushed down the drain simply so she could have some peace of mind and be free of the already overwhelming hospital craziness.
She wanted to be among the first to leave the profession rather than face the ever increasing burdens and patient loads that will be forced on the last to leave.
Thank you for your Nursing support a RN of 50 years things are very bad no staff and administration does care just get the job done
The hospital and system as a whole throw nurses under the bus. I’m a retired ICU nurse. It became increasing difficult to impossible to give patients proper care due to all the boxes that had to be checked per computer and redundant paperwork. Horrible understaffing issues and constant demeaning with no backup from anyone.
The doctors all have each others back. I feel sorry for nurses.
I've noticed this with my son at the hospital it's the nurses who know about the patient and it is a foolish doctor who does not listen to and appreciate nurses
I’m a retired nurse also and totally agree with you.
People from management need someone at the bottom to be their lamb and unfortunately it’s always the nurses to be blamed who also are the working horse of the facilities.
Thank you Z, for standing up for nurses when no one else does. I did forty hard years as an RN, twenty five in hospital, fifteen in a cardiology clinic doing triage for eight cardiologists. The clinic was a cake walk compared to the hospital. It squeezed everything out of me. I am a detail oriented perfectionist and rule stickler, but I made three medication errors in those twenty-five years, because the demands of the job were always at max capacity. Luckily, those patients were not injured, and I went through the reporting and disciplinary protocols, and felt like crap. We are only human, but the system demands super human.
And do you think you should haven gone home at the end of the day if you had killed one of them? Answer honestly. Are you above your patients?
@@this.is.a.username how many more patients would die if everyone in healthcare quit? Think before you speak.
@@nestfeathers88 I'm not letting you hold patients hostage for incompetent nurses.
who said everyone would quit 🤣🤣🤣 I was taught we could go to court if we harmed someone. so sorry you nurses were coddled and taught you were little angels that could get away with murder
@@this.is.a.username how many times have you made an error at work? Maybe you’re lucky enough to work in a industry where the stakes aren’t so high. When something like this happens, it is NEVER one person’s fault. Systemic errors and hazards were rife in this case. It’s easy to throw one person in jail, rather than taking a hard look at how the system allowed a fatal medication error to happen.
@@sharvintarbler6431 I am a radiographer, I insert IVs and push contrast multiple times a day. I push something as thick as maple syrup into patients with a machine 3x faster than any nurse can by hand.
if I fuck up with my machine and injure or kill a patient I know damn well I'm going to court. because that's what I was taught in school.
this has nothing to do with the system, she wasn't over worked or rushed or over loaded with patients... she failed a basic rule and did not verify the medication. she was incompetent.
nurses are coddled and radonda is guilty
As a healthcare worker, I was often told I should go back to become a nurse. I thought about it, but ultimately I decided against it, because I saw first hand the amount of BS they have to go through and the little to no support for the floor bedside care staff. Its too stressful.
This is a huge reason for me retiring after only 10 years. I remember an instructor in nursing school telling our class if we don't get sued, we aren't good nurses. In nursing school. 🤨
@@NatashaNavigating:
That was totally wrong of that instructor.
@@islandgirl8199 I've worked as a nurse with this in my mind with every job I've had. I've experienced the whole "nurses eat their young." I've witnessed facilities' blatant disregard of work-life balance. I'm over it. I'M DONE!
@@NatashaNavigating scary and stressful
@@NatashaNavigating can I ask what are you doing now?
I'm not a nurse but I know that overworked, burned out people in precarious iffy systems concerning safety are bound to make unspeakable mistakes. Nuclear powerplant safety protocols, surgical protocols, aviation protocols etc. are supposed to be carried out by clear headed, rested, "present" people. When you put so much pressure on people, fatigue them and force them to go in autopilot, you create a recipe for disaster. Unimaginable disaster like this.
As a future nurse this is terrifying. Even as a cna, I’m overworked ridiculous ratios so I can only imagine accidentally making a mistake as a nurse.
If you hate the job and are just working it for the pay and benefits….get another job that won’t kill people when you make a mistake. Nursing is a major responsibility that even one mistake can kill someone.
@@Dj.MODÆO Hello, I never said I hated my job. Im sorry but no one works as a CNA for the pay or benefits… it’s barely minimum wage in most states. Yes, I agree nursing is a major responsibility and should go into it for other reasons than it’s pay.
As a nurse for over 40 years I would never recommend a career in nursing, it's a nightmare profession now. Like everything else, it's all about the bottom line.
My step mom tried to talk me pout of it at 18. I am very headstrong and never listened. Now after covid I want out of this field.
I want to be a hospice nurse. 😭 Every nurse I’ve met says to pick another career.
I agree with you on that and I am not a nurse. And yet a lot of people around me seem to still want to go into nursing.
I would have chosen a different profession if I had know 16 years in and another 30 years to go :(
@@s.k.1603 they have no idea how unbelievably stressful, emotionally and physically nursing is . Corporations and insurance companies has completely over healthcare and hospitals. At least for a decade now if not longer , the CEO and BOD slashed our staffing in the ICU to barebones, always short staffed and severely short staffed on the weekends, forget about support staff, non existent. A living hell, not to mention EPIC computer system, where nurses spend 3/4 hours covering their asses.
I love listening to you because you hit the nail on the head everytime. As a nurse I know how it is and unfortunately unless someone is in our shoes, they wont realize the struggles we face each shift. One has to be in it to know it.
No. He did not. He mentioned a huge problem, yes, but the nurse made this mistake, and had she not, this would be a nonissue.
Million Nurses March is coming up.
I'll be carrying a sign for Rodonda.
It could have been me.
Everyone e doesn't understand how nurses hold everything together, while the clipboard carrier walk around and find crap to peck at you about.
you sound like a white cop justifying shooting a 10yr old with a toy gun. leave the profession, i don't want to work with you.
Amen
I gave birth in November & my brand new baby spent eight days in NICU on a ventilator due to nurse error. But I made sure that the administrators did not fire the two nurses who caused her injury because I genuinely felt like they did their best & took as good of care of my baby & me as they could have given the circumstances. The hospital assured me that their protocol is just culture. One of the nurses took a photo on my phone of my husband & I holding one another in our sleep in the hospital bed once our daughter was resuscitated & stabilized & I will cherish that photo forever. The nurses both were devastated by their mistake & kept close tabs on our baby's condition while she was in NICU. It was undeniably their mistake, but it should not cost them their career. & I'm relieved that it didn't.
That is very mature of you. We are very sue happy here.
Im so thankful your baby is ok 🙏🏻🙏🏻🙏🏻
She will have no long term health effects, thank god, so we are just happy she will be okay! It would be a different story, of course, if she would have had long term injury.
If your baby would have died because of them, would you still feel the same?
@@user-es5jq6yy9l definitely not, as I said in an above comment. We thought she was dead... & when she went to NICU, we thought she would be there for months. & we thought she would never be "normal" due to her injury either. But throughout that process, we were also talking with hospital admin, who were of course, covering their own asses. & what mattered more to us while we were in the thick of it was understanding what happened, not placing blame & pointing fingers. & maybe it's because I work in healthcare, but I genuinely felt sorry for the two nurses who hurt my baby. I can't imagine the guilt they felt. The same nurse who took the photo of my husband & me also held me as I cried, wiped my tears, & shed a few of her own. She never meant to hurt my baby. & it was more her inaction that caused my baby harm. Working in healthcare, you see how easy it is for these mistakes to get made & you sympathize with those who make them. & feel glad that it wasn't you... this time.
This is exactly why I left bedside nursing and went into aesthetics. I worked in the ER/ICU. Nothing but short staffed, overworked, underpaid, and disposable to the larger hospital systems. This conviction is a disgrace to all medical professionals and it will cause already bad issues to become worse.
I'm glad you left. People like you kill the old, sick, and injured like us because you're sleepy after a day of work
Yeah right, it's always someone elses fault but never yours.
CAN'T SHE FXXXXXX READ?
She's still at fault. Take accountability for your mistakes. Pathetic to excuse her recklessness. Shame on you.
@@ezrahafner579 That’s a very ignorant, small minded statement
@@ezrahafner579 Are you a nurse? Did you even listen to the video at all? Nurses go through moral distress every day because we know we can't take care of everybody assigned to us. We barely have time to go on breaks, or it will be 8 hours before we realize we haven't peed yet, and here we are running around making sure all our patients eat, get their pain meds, pee/poop. Then, one patient is vomiting now. The CNA is flagging the nurse for an oxygen saturation of 82% for another patient. The doctors, family members, physical therapists, case managers, and transporters also need to talk to the nurse. Nurses are the contact person for the patient at any given time. Oh, and sometimes there's a nursing student/ orientee tagging along too, so on top of all that you need to take the time to explain things to them too! It seems no one has compassion for nurses anymore, and this profession is fizzling out real fast. And I agree, I hope Naomi for your sake, you won't need any type of health care when that breaking point happens.
1) Ignored and overrode warnings on Pyxis
2) Went to an entirely different pyxis at a different dept to dispense the vecuronium
3) Didn't read warning labels on vial
4) Reconstituted the vecuronium for administration (powder to liquid)
5) Disobeyed the 5 rights of medication use: "right patient, the right drug, the right time, the right dose, and the right route"
6) During the PT's PET scan, diaphragm and intercostal muscles were unable to contract due to the vecuronium. Thus, PT slowly became unable to breathe, all while fully conscious, and then died. A torturous way to go.
And yet, she has the audacity to blame anyone else? She is a failure of a nurse and may she rot in prison for her grotesque neglect. In my eyes, people have been too lenient with her. Had it been my family member that was slowly tortured to death, I would have blown this nurse's brains out.
We shouldn't criminalize nurses for making medication errors? So when my father dies due to a nurse making a medication error, the nurse should just get a slap on the wrist? What kind of precedent does that set? You kill anyone in my family, I will hunt you down.
Thank you for addressing this issue. I’m a nurse practitioner and I worked in a system (not my hospital) where nurses would beg me to cover their errors with an order because the nurses would get punished for any med error. This is so sad! Everyone has made a mistake but it’s really important to find the root cause of the error. If nurses fear retribution, errors will never be reported and the issues can not be fixed.
I believe in the local paper in Nashville it was stated by the journalist that the patient's family was aware of the error. They had not been made aware of what occurred with their Mom at the time, but even when everything came to light they did not vilify the nurse. That should speak volumes.
No one wants to even TRY to understand how difficult being a nurse really and truly is hard as hell. Everyone thinks we sit around and talk and drink coffee and are lazy. We sit because it may be the few fleeting moments in a 12 hour shift we are actually ABLE to do so. We drink coffee because our jobs are physically and mentally exhausting and caffeine is sometimes the only thing we have to keep us going because we didn’t get a real lunch break. But when we make a mistake, we aren’t supposed to be human and now we are criminals on top of it. What happened was tragic, but putting a nurse in jail because of a med error proves nothing and accomplishes even less.
I'm hoping this story doesn't end here, and hoping this nurse will have the support to fight this decision. Back in early 80's in Toronto's Sick Kids hosp a nurse (Susan Nelles) was charged w murder of many babies. It's a very interesting case and the easiest resolution at the time was to blame the nurses however she was able to clear her name and continue with her career.
I couldn’t agree more👏🏾
1) Ignored and overrode warnings on Pyxis
2) Went to an entirely different pyxis at a different dept to dispense the vecuronium
3) Didn't read warning labels on vial
4) Reconstituted the vecuronium for administration (powder to liquid)
5) Disobeyed the 5 rights of medication use: "right patient, the right drug, the right time, the right dose, and the right route"
6) During the PT's PET scan, diaphragm and intercostal muscles were unable to contract due to the vecuronium. Thus, PT slowly became unable to breathe, all while fully conscious, and then died. A torturous way to go.
And yet, she has the audacity to blame anyone else? She is a failure of a nurse and may she rot in prison for her grotesque neglect. In my eyes, people have been too lenient with her. Had it been my family member that was slowly tortured to death, I would have blown this nurse's brains out.
Yall don't do this sad sob story shit with the police.
You're right. Not just coffee n sit around. Tik tok dances lol 🤣🤣🤣 heros
RN for 30 years and this breaks my heart all around. I wouldn’t advise anyone to go into nursing these days, especially, after this.
This is why we need nursing UNIONS to hold administrators responsible for providing support for nurses and all hospital staff. Patient safety over profits.
RN went on to earn DO. I would avoid the medical field as a whole. Nurses are constantly understaffed… docs are not allowed to do the right thing.
@ZITI Notgivingawaythisinfo Of course, but the doctor explains how this was also a failure at several other levels. There are typically several backup systems in place to prevent errors like this and the hospital and specifically administrators are at fault for not having those running properly.
In Canada we have unions for nurses, they too have failed us from their early years when they truly did improve the working conditions.
@@joywebster2678 That's a shame. I can honestly say that, so far, my union, UNAC/UHCP has been a part of creating safety measures and holding administration accountable for their action and inaction. Unions in California brought about staffing ratios, which have been a big help. It isn't perfect but if an error is made because the hospital isn't following the rules and we've submitted a staffing objection, we are protected.
@@ADHDGG and i worked for 10 years in California, and wasnt impressed. Headed back to Canada once my Phd was complete.
They float us, we are treated like a heartbeat with a RN license. For my whole career, I was afraid of hurting someone. This has been going on since the 80s when I graduated. My heart goes out to her, couldn’t imagine the pain each day she is feeling.
Nurses feel more sympathy for each other than for the lives they take.
No condolences for the woman who died a slow and painful death?
@@ezrahafner579 many nurses have no sympathy for their fellow nurses. Glad I retired. It’s a toxic work environment.
@@ezrahafner579 you are not a nurse. Don't judge til you are a nurse.
@@deanagallatin6974 i don't have to be a nurse to know that when you have someone's life in your hands, taking that lightly by overriding safety measures is despicable. if being a nurse means taking life accidentally is brushed off and smiled at, im so glad i never chose that path
Just adding to our understaffed nurse issue. Being understaffed= being overworked. Being overworked= stress and mistakes. This is so sad.
This isn’t like working in the deli. I’m reading all these comments ….walk out if you guys cannot give quality care to patients walk out. If all the nurses and doctors got together and did something about this these hospitals wouldn’t be able to do what they do.
@@lauriebennett5136 it's not that simple. People are already having to wait for important surgeries and care because hospitals are understaffed. There needs to be accountability on the facilities and business aspect.
My first LVN job was at a senior living facility. It was part of a huge national corporation that has locations all over. During my second week of orientation, I made a med error. For context, this facility was set up kind of like a hotel, with 5 or 6 floors. I figured each floor had a couple nurses with med carts who would pass meds. Nope. They had ALL the residents wheel themselves onto the elevator and go to the 3rd floor "med room" to take their meds. All at pretty much the same time. Imagine a doctor's office lobby-sized room, with a doorway to an office (nurse's station), where we had the computers and meds, with at least 20 elderly people at a time, most in wheelchairs, waiting around for not only their medications, but their topical treatments. I literally had to take a gentleman to the back room to apply his topical penis medication. (wtf?)
So the guy training me took me to a computer and told me to start at the top of the list of patients and work my way down. I was still very unfamiliar with their EHR, and there were people sitting around complaining about the wait. I gathered all the pills for the first patient, and brought them to the nurse training me, and asked how I'm supposed to identify the right patient. He looked at the name and said, "Oh, she's the one with the purple shirt and glasses" and kind of gestured in a general direction. I look over and I see a lady with a purple shirt and glasses and say, "Are you Mrs. So-and-so?" And she's all nodding and saying "Yes, dear." I give her the pills, she takes them, and I turn to walk away and see another woman with a purple shirt and glasses. Holy shit. My first med error. I told the other nurse about my mistake right away, and he got all bitchy and told me to go sit in the back.
Later on, the manager boss guy (who was never a medical professional of any sort) reamed my ass. I can't remember his exact words but he made me feel terrible. I tried to explain that I was still learning and that the situation was really confusing at the time, and that I'll never do this again, etc. He didn't care and pretty much told me I would be fired if I did anything like that again. I, of course, quit without notice. Boss man was all, "So you're not giving notice??" I told him that I still had three weeks of orienting left; I didn't think giving notice made sense. Turns out, he was planning on making me work NOC shift alone for the next week.
The lady I gave the wrong pills to turned out to be fine. Most of the meds were actually the same ones she normally took; there was one other, can't remember which, but the doctor said she would be fine. They had me call the lady's daughter and tell her I gave her mom the wrong meds, but the daughter was so nice and understanding about it (I apologized profusely; I felt so bad).
So, yeah, that was my long-ass-winded way of saying that I, too, am RaDonda.
I'm really sorry that happened to you...i have witnessed abuse of the pts before, by other nurses and admin, and when reported was basically told i was a shit starter and not a team player, i left obvi... facilities constantly ask their nurses to do illegal stuff, then get mad when you want to quit without notice.
I am sorry that happened to you. I have been in that situation where patients don't wear an ID band because someone decided that an ID band invaded the patients privacy.
Don't you love the way there is no way of identifying people in long term care. You actually have to learn and memorize at least 100 strangers faces. Why havent the Hotshots at Medicare and Medicade Services come up with a safe and effective way to identify outside of an old photo in your patients chart that looks nothing like them.
@@mariacullati2371 Cuz somehow just yelling out their names and meds is better than a band u have to get up close to read. Our systems....
Yeah but that’s not the same as Redonda Vaught’s mistake. In ltc some of the residents have hearing problems or dementia or have aphasia etc that prevent them from understanding or being able to communicate. When I worked in different facilities there was a name & picture by the resident’s door & the nurse or med tech learned overtime who was who. But standing in line with no wrist band/badge is risky. It’s good you quit.
ZDogg, you're late to the party. Increasing criminalization within medicine has rocketed the last 10 years. You're absolutely right to bring up the "systemic errors." The Pixis releasing a medication with only 2 letters entered is an "administration" issue. With the thousands of medications, no distribution system should dispense a med with only 2 letters entered.
@ Dennis Geyer The Pyxis drawer shouldn't even open up for a high risk med like that without a witness Nurse logging in first.
@@rhondadeakin8051 clearly you've never worked in the ER or critical care.
It is still her job to double check… hers…
@@dawnchute7449 Ma'am, if you would kindly review my remarks, you'll notice I did not weigh into her negligence. I simply reaffirmed ZDogg's assertion that there were systemic contributions to this mess. A machine should not dispense medications based upon entering only 2 letters. Now, please reflect on the many near misses in your life and count your blessings that things go bad....
@@frankherthem1794 I've worked both ER and Critical Care and many others. I've been a nurse since the 1980's so , clearly, you have been working in systems like Vanderbilt who operate below the standard.
Thank you for supporting her. In public.
How could something like this happen. Not the med error the conviction. I'm a nurse of 45 years and I CANNOT believe the direction that my beloved profession is going.
Great recap of this entire case! Although you are a physician, and not a nurse..you really hit the nail on the head. Thank you for understanding what we go through everyday.
The other day I was asked to pull IV Ativan and take it down to MRI to administer to a confused, disoriented, anxious patient.
I had to pull the medication on the unit, draw it up, then put it in my pocket to run downstairs to administer. There was no way to scan the patient, check allergies, look at the order etc. All I could think about was this case. “What if something goes wrong? What if she goes unresponsive?” And honestly, I feel like I had no choice in the matter or else I would have been “talked to” by management for delaying patient care.
Everyone in healthcare is putting their license on the line on a daily basis..but more importantly, these hospitals are putting their patients at risk knowing they won’t be reprimanded. They will just fire the nurse, the physician, the RT..and move on.
Oh and plus, while you were gone giving the medicine off the floor and monitoring the patient for the med you just gave, who is watching your other 5-7 patients? I have been there and done that too.
I have been teaching nursing students now for 17 years. During that time as I observe what is happening on different units, I have seen an increase in dependency on technology and an increase in specialization within medicine. The result is too much dependency on technology without using critical thinking skills and too much focus on charting with less time at the bedside. The ultra specialized focus of providers also means gaps in appropriate treatment and communication which can result in patient harm.
❤❤❤
Hi Lynn, Thank you for your post. 3 year RN here and going back to school for my MSN in education. I'm very interested in what nursing is becoming. Moving forward I think things will get worse before they get better. If they ever get better. I know this sounds bleak but I believe as nurses we have to face the reality in order to fight for a better future in nursing.
Please, teach your new nurses to clean the IV ports EVERYTIME before they insert anything into a patients veins
@@teresaterezia7982 Really???
And you should know, then that the constant push for advanced degrees has had an influence on this trend. Not to mention, pushing the nonsense that AASNs aren't worthy, Magnet status seeking hospitals, the merging of hospitals into large corporate entities pushing a "customer service" mentality and patients expecting concierge service...I could go on, but I think you hear me.
There is no way to ACTUALLY accomplish everything a bedside nurse is SUPPOSED to accomplish in any given shift.
Correct and the reason why I dropped out of my RN school program after 2 semesters.
That's why report is given to the oncoming shift...continuation of care
Unfortunately, it appears that these hospitals are “too big too fail” as happened with the banks. The money given to hospitals and universities is so large and becomes a conflict of interest in regulation. This is very sad for all medical professionals and more so for patients and their safety.
This is very sad that most people including this guy don’t know the very pertinent details of this case to prove blatant negligence. As a registered nurse she skipped every step of basic standards of care & she knew what versed was as it was proven she’s given it several other times before! Trust me, a vecuronium vial is very very clearly labeled with fatal warnings ⛔️ and you have to mix it with saline. She absolutely had to look at the vial & do an extra step not usually done to other meds and never done for versed! There is something quite strange about it.
Also interesting…he keeps saying “did she have intent”? That’s not relevant! Think of all the criminal cases that happen where intent is not involved. Fatal accidents (car, machine accident, police, etc etc) don’t always have intent but depending on the situation (case by case) criminal negligence can apply.
@@birdgirl1516 Seriously, if cops were held to the same standard as nurses....
Can you imagine a cop self-reporting? How about a cop that gets fired from one job and just goes to the next town over, or the next state. A nurse could never do that. Our administration actually holds us accountable unlike the cops who investigate themselves and find nothing was done wrong. If we do anything outside our scope of practice we're actually fined by our state board or we could lose our license. That never happens to a cop. Absolutely never has happened.
Comparing what we do to somebody falling asleep in a car when they're driving down the road is ridiculous.
"Preach on brother!" Every time I hear your rants that's what goes on in my mind. You truly get the nurse's struggle and the healthcare mess as it is. I also appreciate your humor and pessimistic optimism for change.
I am an MD and at one point several years ago we implemented an EMR at a state hospital that was weak. The MD job went from writing orders to putting them into the system ourselves (like the secretary had done) but the system was full of things requiring override, to the point where no one could enter anything without having done at least one override. The fatigue is real.
Also, if the patient was there for a subdural (which is what I heard somewhere), then why would she be getting a PET scan at all?? There are some brain bleeds that are cancers but those aren’t usually subdurals and generally the intraparenchymal tumors aren’t visible with the blood still present. If she was stable enough for discharge then why not set up the PET as an outpatient?
Great summary of the system issues and lack of accountability where it is needed.
At this point, I don't know enough to say whether or not this was a criminal event. I am a seasoned ICU/ER/Flight RN and a boarded ER NP. I don't understand two parts. 1) Versed is a fat vial in brown glass and typically a green top. Vecuronium is a powder in clear glass, with typically a red top. It must be reconstitued. That alone should have triggered something in her mind. In the ICU, versed is given regularily. 2) when would you give an IV sedative and walk away and leave a patient without monitoring. Especially an older patient with a head bleed. As I understand the situation, the nurse was an ICU nurse. She should know standard of care.
I wasn't there. But on the surface, this seems so off. Vecuronium is survivable if she had stayed with the patient. Bag valve mask would have been enough to keep the patient alive.
Again, I wasn't there. But I find these events difficult to wrap my head around. Medical errors happen every day. If the error was genuine, then it shouldn't be considered criminal. We couldn't function in health care if medical errors were treated as criminal offenses.
At my facility, the packaging of versed and vecuronium is different from the packaging you had mentioned, which means there are different ways of packaging those medicines. And throughout the past 2 years with all the shortages over covid, the packaging kept changing due to different distribution companies. In our intubation kits, I DO NOT remember our paralytic agents actually having warnings about them being paralytic agents either; we are just supposed to know that they are.
After the med was given, pt went into scanner. If it was an MRI, she couldn't monitor. Why did radiology not report that she was not responding over intercom?
I agree! I think we are in the minority though. She made many, many mistakes and did not double check herself.
Anybody could make mistake at any time. May we not be victims, in Jesus' name. Amen.
What this will serve to result in is so far reaching it mind boggling. No one will feel comfortable reporting medication errors and there will be fewer people going into a profession which is already suffering a nursing shortage. Vanderbilt actually covered this up. Those perpetrating the cover up should be charged too!!
@Caitlyn A easy for you to speak when you have no perspective and our on the other side. I am sure you have made mistakes in your job you are human, so is every other nurse. On top of that this was a cover up from the hospital.
@Caitlyn A well you’re perfect I guess.
@Caitlyn A when you deal with someones life all the time in your job you become somewhat desensitized with respect to being extra careful. Hours and hours of being careful doesnt just happen. Your logic would cause even bigger shortage and even more errors.
@Caitlyn A its realy not that difficult to understand if you work in that kind of pressure. Not justifying her mistake but prison is too much for that.
And prison is only gonna make the problem worse. Nobody is gonna report if they accidentally did something wrong.
@Caitlyn A we will only know how this effects healthcare in a few years. Mistakes are bound to happen when you make someone work long hours.
I can relate a lot to being normalized to alerts/messaging etc. I’m a pharmacist and sometimes after a long day, in a chaotic environment, verification fatigue is something that’s very concerning to me. You can almost see a name of a drug that you know should be there when it’s not. Pop up for everything, your fingers almost hit the button without you even consciously processing you’re doing it. It’s hard to explain if you haven’t had the first hand experience. I can also understand even reconstituting something under pressure. When you are distracted and doing a task that’s so familiar to you, it’s not always as simple as, “this drug is never in powder form.” I think it’s human nature to kind of go into a robotic mode when you do something frequently enough. That’s why it’s so important that the hospitals or systems you work under are well designed and well executed.
The scrutiny is misguided. Intent and root causes are so important in situations that are bigger than the incidents themselves. Her intent was not one of a criminal; the remorse and devastation are evident. The root causes however, those are alarming. The focus needs to be on how insane it is that this person was working in such an environment that it seems bizarre she could make this error. Not that she was insane for making it but that she could have made it based on circumstances as practices of that hospital.
intent is irrelevant. mistake does not absolve consequences.
@@this.is.a.username let's hope that you don't have to be held accountable for an accident.
Consequences such as having to go on knowing that your mistake cost someone their life.
I am amazed by your lack of compassion. Are you part of corporate America?
@@loriflatland3142 My compassion is strictly held for patients, not for incompetent nurses being paid more to cry louder.
I need to see this trial or read the testimony.
@@this.is.a.username With all do respect everyone makes mistakes. Vanderbilt is not shouldering any of the responsibility for this tragedy.
Why has a the nurse made to accept all of the consequences?
Her life is ruined. It's not fair.
There are so many nuances to this case.
This story makes me so, so sad for ALL involved! It’s a cautionary tale for those of us in healthcare. And yes, so easy to see how it could absolutely happen to any of us.
I swear, I had guardian angels. I wanted to be a nurse, but they were focused on getting older women, women of color and men. After three attempts I was advised to “do something else, try again in a few years. Stayed in school, took a job as a secretary and ended up being a flight attendant. Just retired after a satisfying 47 years of loving my job and seeing the world. Guardian angels❤
1. I’ve made med errors.
2. I bawled my eyes out for days over things that hurt no one, but they *could* have.
3. We can’t remember literally everything with all the distractions we manage. Systems need to make our jobs easier - not harder. The system has the potential for software that handles all the pt rights. We need it to be in place.
But you know the difference between Vec and Versed. We give it all the time in the ER and I would think ICU as well. It’s really hard to mix those up. I just can’t wrap my head around how she could be that dumb. Unless we’re missing part of the story. But wow. I do feel horrible for her, but her ignorance caused a sentinel event.
@trauma queen This is why I went into the administrative side; heard an RN friend of mine bereft on possibly having killed a patient. Currently helping build an EMR. Would love to hear of anything you would recommend to alleviate this mess. TIA
@@kimmontenegro2258 I feel like the hospitals have done a great job at putting stopchecks on dangerous meds. It’s really up to the preceptors to really hammer home the need to know what you’re giving. When I was a new nurse in 1992, we used to keep Saline flush vials in a drawer next to KCL 40 meq vials. Same size, different color caps. Of course a careless nurse pulled out a KCL to flush a lock and killed a patient. Much safer now.
being sorry doesn't absolve you from criminal consequences of your actions.
@@this.is.a.username absolutely correct John. Justice should never be tempered with mercy. Every potential healthcare worker should be warned that any mistake made can lead to prison time. How many will choose a different profession? Maybe there won’t be any humans available when you need medial care. You can always go back to your family for care. I actually pity you.
I’m an anesthesiologist. Not monitoring an elderly pt with a head bleed that you are giving sedation to IS criminally negligent. The accidental med swap is not criminal despite the many context clues that she was doing something wrong. However, even if she had only given Versed, she still could have killed this pt due to the obvious lack of monitoring. At minimum, an ICU RN should be monitoring this pts respiratory rate after giving sedation. It’s obvious she gave the med and walked away. This IS criminal and not a simple mistake. The med swap could have been a simple mistake. However, even with the accidental med swap, this pt did not have to die. And should not have died.
True, every time when I have brought a patient out of the ER or ICU and they required sedation, it is our policy that they stay on monitor at all times, and we are there. Would be interesting to see what their policy is.
Do we know if she was interrupted by another need which distracted her from her duties?
A preceptor is generally a person picked by supervisors who typically meets or exceeds standards of care.
Their might be alternative reasons why she left. A needed bathroom break, left in the care of another, or someone equally in need close by needing her attention.
I haven't read any transcripts, sounds like you definitely know more than I. Just wondering....
@@loriflatland3142 from what I read, I didn't hear anything about distractions, but honestly knows. Very true about having to be good to be a preceptor, can make or break a new staff member
so. many. things. when i first heard the case was she gave vecuronium instead of versed as a "sedative", my first thought without knowing anything about the case, was why is the pt. getting the big guns right off the bat?! you dont just causally give Versed. seems extremely risky to give a pt. Versed and then shove them in a CT scanner? It doesnt make sense. Also for many years our hospital has been very cautious about which drugs are on override, always weighing risk/benefit. Override medication allowances are decided by a multidisciplinary group. paralytics are seperated, in a box with a lid with big warnings. we also are particular about the allowance of alerts, for ursing alerts several parties have to agree on activating an alert, ensuring its an end user benefit, not just admin thinking its a good idea. Vanderbilt is culpable for sure. Never stop being humble. This while thing is terrible and terrifying. depending on circumstances, any nurse could be a this nurse.
@@cl8350 you are right, it could be any of us. We also have the meds locked up in a box and zip tied, and I always call them the "nuclear option", because you give them you better be ready. Yeah, versed usually isn't a first or second line drug, so would definitely like to know more
43 years as an RN in critical care nursing, I am glad I an retired. In the military none of the systems talk to each other, let alone from one hospital to another. Our computer system where I worked would not have my patient on any Pyxis but my unit. Could not override it either. If We moved a patient from one unit to another, we could not get ANY meds till the Pharmacist checked everyone of the med orders.
I am an RN of 22 years but have not worked in the hospital for a while. I have made errors and am fully aware that anyone of us could cause an error leading to serious harm. I don't think this RN should be prosecuted but there were multiple barriers/red flags that this Nurse chose to bypass. The biggest being having a powdered medication which needed to be reconstituted when Versed doesn't come that way. Also, not monitoring the patient while in the MRI. What do you think? Is this being too harsh or was this beyond a usual error that is because of process issues?
@@DB-lo9jp hmmm. Not commenting overall on the case (im still absorbing it) but the reconstitution issue is quite an excellent point.
@@DB-lo9jp 100% agree that this nurse does hold some responsibility here. The reconstituition issue is a huge flag… though how would it be prosecuted legally and who would be really to blame for that misjudgment? Is this a lack of judgement on her part, is it a lack of education from the system? Or how does one weigh in “common sense” from a legal standpoint? This is a really interesting case, though I don’t feel the verdict is correct. I don’t work healthcare but know enough to think of Versed as being strange coming in a powdered form. Like I honestly think you have to be kinda dumb as a healthcare provider to think that a medication of that class would need to be reconstituted. Versed is often an emergency use drug, there’s no time for reconstitution, why wouldn’t a nurse think twice here? For me, this lack of “common sense” is the biggest error on the nurses part.
@@marial3231 it may help to know that RaDonda had only been an RN for 2 years. She graduated in 2015 and this situation occurred in 2017. I’ve been wondering how she was: working in the ICU, acting as a float nurse (which included the ED) and training a new nurse with such a small amount of nursing experience. With the nursing shortage, the levels of nursing experience required have decreased. And she is paying the price.
@@marial3231 Clearly lack of clinical skills. If she knew her drugs better she cannot get confused. If you cannot differentiate between versed and vecuronium, and still go on to reconstitute it and then leave the patient, without even watching them, I would say that is pretty gross negligence right there.
As a “retired” RN who got the hell out, thank you!!!!!! I do appreciate every truthful word you said. Floor nursing is a scary shit show and that’s why nurses do not want to work doing that job. Although I miss taking care of the patients. And I miss the comraderie of my fellow coworkers.
You know what's scary? Laying in a machine after your nurse promised to give you something to help you relax, only to realize that it's becoming harder to breathe, you can't move, and you can't speak. THAT'S scary shit.
I have been an RN for 45 years. I was hoping to make it to 50 years, but seriously rethinking that. He didn't even mention the 12 hours shifts. I used to have 11 patients on the night shift in the 80's. I still often have 11 patients on the night shift who are sicker than ever, and we have few supports than ever. (no housekeeping, unit clerks and far fewer nursing assistants). I have made med errors in the past and live in terror of making a serious medication error of this sort.
As a travel nurse, I have to regularly navigate a variety of different medication rooms and EMR’s and I find this very worrisome.
Why in the world would any hospital have Vecuronium available anywhere but in a crash cart or in the ICU?
It should be a two RN sign off like insulin or heparin.
Mistakes happen and when they do, they are absolutely devastating to all involved.
Which is why a full disclosure of events is encouraged, in order to help mitigate the possibility of reoccurrence and to help keep patients safe.
If a nurse feels as though she may go to prison for an honest mistake, My God how is that going to help anything?
I can’t help but wonder if she’s being railroaded somehow to protect the hospital?
Excellent point-any potentially lethal medicines should be under a two-party sign-in system.
I'd add such medicines need to be kept in a separate database entirely.
This would help to lesson medical mistakes like this.
I don’t think she was charged for making the mistake I think she was charged because there were multiple times when she could of caught the mistake
Including the medication she give was Powder when the medication she was supposed to give is a liquid so she was found grossly negligent I’m not saying she should of been charged as I don’t think she should e but think her and the hospital should be financially liable
She didn’t just make a “mistake” she deliberately ignored all of her training. There is a huge difference and that difference is what warranted her conviction.
You’re not a nurse.
@@jasminecrandall2262 I've been a nurse for 23 years. And?
I have worked in hospitals for 30 years including 2 years of the pandemic. When I compare how I felt about this case before I watched your video and how I feel now it amazes me how the regular media distorts reality. Thank for this amazing example of the complexity of the real world.
I’ve been a nurse for 14 years and I’m just done with healthcare. This poor nurse. We are all her. How the hell can she be given criminal charges for an error?
My dad with multi organ failure was deprived of 6 Liters of oxygen for 30 minutes by an ultrasound tech that told him, “You can’t have my tank,” and pushed him in the hall with no O2. That’s deliberate indifference and she still has a job. Joint commission never responded to my complaint either. Yet a nurse was honest about an error and was thrown under the bus and backed over. Shameful.
I work in a hospital that cohorts COVID patients in double rooms not knowing what variant they have. WTF?
Moral injury is taking its toll. I’m a 14 year nurse about to exit ASAP.
In Texas I've seen a ton of mistakes and been on the receiving end of them.
This nurse seemed innocent but we need to have a talk about how hospitals at times need improvement
Whats worse is that it's hard to sue
So you purposefully ignore and skip all the warnings set in place and think its just an oopsie when you kill someone? Good, be done, you're a danger to patients. You think you are too good to read the through warnings? Skip skip yeah yeah blah blah. Then quit and go something where lives do not depend on you being too good to do it right.
Sickening it was a terrible accident
Because she killed a patient.
I'm with you and really we are all suffering from ptsd since covid. Im absolutely devastated that she was criminally charged.
Working at risk management in a hospital I am shocked and the hospital should be held responsible for the cover up.
👏👏👏👏👏👏👏
Healthcare is so under staffed. You can't expect people to not make mistakes. Their is no help for healthcare workers. I'm a CNA and I run from room to room. No lunch, no break, getting yelled at by family, patients and most days we have 12 to 18 patients. Healthcare workers can't give good quality care if they have too many patients because of under staffing. I love my job and wanted to look into nursing but no longer.
I am a retired (thank God!!) RN. When I was nursing it was well known the med errors were common and were almost Always considered a 'Systemic Problem'. As you said, there are So Many contributing factors, and I can only imagine how much worse this has become with the stresses of Covid, undestaffing, etc.
This charge of this nurse will only cause fewer people from entering Nursing.I have a 30 yo daughter who has been in Nursing less than 10 yrs and is already considering leaving! I can remember working Psych 12 HR shifts (extending to 14 hrs due to report, sick staff calling in last minute). Frequently no time for a snack or pee break!! And no pension either! I retired in my late 50's due to work related back injuries, surgeries. My SSDI payment (my only income)? Less than $1000/mo, 200% below poverty!
I hope and pray people take your message to Heart!!!
You got SSDI for back injuries? Cool. I have Limited systemic sclerosis, rheumatoid arthritis, sjogrens disease and a work related back injury, major depressive disorder and PTSD. I WANT THE NAME OF YOUR LAWYER! LOL
I resigned from a workplace because of how the company continued to run understaffed while over admitting patients leading me to cut corners and lower standards in order to survive the shift. As a nurse we can easily become complacent or overworked, especially nowadays. We have a responsibility to our patients and to ourselves to check ourselves when this happens, make the changes needed and/or walk away. And yes, EPIC is trash. On a second note, I'm really interested in the opinion of who she was training when she pulled the wrong med.
Isn't this the definition of every company and unit?
I resigned too.
I have 2 more shifts in a work environment like you describe. Just last week, (short staffed again), a nurse was tending a known violent patient. The patient assaulted the nurse, punched her in the face and when she reported the incident, administration blamed her "because she should have known.".....2 more shifts to go and I'm out.
"We refused to unionize"
That's all I read from you.
We’re definitely overworked. A lot of times we went 12+ hours without a break, a meal, or fluids where I worked. If you did get a break, it was continuously interrupted leading to no meals.
All that needs to happen to fix this situation is not having meds auto-populate on the pixis when you type in 1 or 2 letters, it's not rocket science.
Thanks for the detailed description. Alert fatigue and systemic overlooks of policy is a huge issue. Yes, healthcare workers should be held accountable for their mistakes but not criminally
Following this devastating case, our hospital reassessed individual units and removed unaligning meds from Pyxis system. Certain critical meds are placed in higher controlled storage units which cannot be bypassed and will need pharmacy verification prior to authorized dispensation.
The fact that the hospital did not report this tells me that they were afraid they were at fault.
I retired after 45 years as an RN. This totally sickens me. Why would anyone want to go into nursing after this? Why would they have that med in radiology? My heart breaks for this nurse. She has to live with her error daily. 😪
As a patient, I’m worried the only people left to care for my family will be the ones who think they don’t make mistakes.
They have that med in radiology for patients who are intubated so they don't self extubate
@@tonyjerry l understand but wouldn't you think they'd have protocols for frequent vital signs and monitoring? I'm sure l don't know all of the details. The whole thing is just sad.
The thing is she made numerous errors, not just one. Criminally negligent though? I don't know about that. Depends on the exact definition that was read in court to the jury. In any case, I wish her well and healing for everyone involved.
"Error"? Nope. Not an "error". Negligence.
Hospitals can be the absolute worst; management just doesn’t have your back. They’ll run you ragged for unfair pay, charge the patients through the nose for it and if you’re fatigued or overwhelmed that’s your problem. It’s not about patient care or staff retention anymore it’s all about the bottom dollar
Another great video as always. Thank you for sticking up for all healthcare workers.
How hard is it to double check the name of the medication before administering it? I don’t get that it’s hard for anyone? Lawyers double check and recheck their documents (word by word). But they can’t check name of the medication right before giving it to a patient? What am I missing? We are talking about human LIFE not a word error or a headache or a cut. This is LIFE and DEATH. Come on.
If this happened to me or my family member I would not want this nurse in prison. Mistakes happen and we learn from them. No one is perfect, prison should be there for true criminals.
@Caitlyn A which is handled by the board of nursing, troll
As someone who studied industrial engineering with an emphasis on information systems on the graduate level, I was stunned that this system was set up so badly, though still puzzled that the nurse persisted. Back in the 80s and 90s, there was a huge emphasis on human factors, on designing systems that made it easier to get things right, but all of that seems to have gone out the window in the name of cost-cutting so we can afford socialized medicine. Anyway, organizing meds by brand name instead of by therapeutic category, just for openers, was a bad choice; I also read about another similar case involving a med that had the same two first letters as another inappropriate one. At least there were warning messages (but maybe too many petty ones.) Designing these information systems is an art, and they need to undergo substantial testing, including with very tired subjects!
".... in the name of cost-cutting so we can afford socialized medicine ...." While I agree with most of your comment, this statement of yours is just plain wrong. Allow me to fix it: ..... in the name of cost-cutting so corporations can make more profit for their investors and top management ..... There, reality.
You nailed it. ACA changed everything. Bc we were all forced to go to eMR’s, which by the way also invades a patients’ privacy. There is no easy way to switch to eMR’s without medical errors during the transition. EPIC was going to be the BEST ever and transform healthcare. Not so much. This is all by design for socialized medicine. Everything it seems has a pathway and a registry to meet benchmarks on meds. So who really makes the money? It is NOT the hospitals. Hospitals are short staffed since ACA. Many negative unintentional consequences. The hospital has much accountability in this case. Not the nurse.
@@angelac8812 Yes, the hospital has responsibility here. However, how exactly did the ACA cause hospitals to understaff? Seriously, I'd like to know the connection if you would be so kind as to explain. And what's eMR's and EPIC? Also, what's wrong with socialized medicine, exactly, or aspects of it?
And unfortunately, they have purged all critically thinking employees from health systems across the board in the last year. This problem will get worse.
@@angelac8812 Yes, I've read hundreds of complaints about the eMR's! The bureaucrats really took over. I wondered who they were. Were they doctors and/or nurses who had left practice? How many doctors and nurses get frustrated with their work and take those jobs? I wish someone would take an inside look at all that. (Granted, I know about the USPSTF had some influence, but their findings were a starting point for the bureaucrats.)
My greatest fear is having to go to the hospital outside of a general visit.
The system needs a complete overhaul. This should never happen. However tragically there were too many mistakes made by DaRonda. "One unfortunate oversight/error" is one thing, but just way too many on her part - but she is certainly not entirely to blame. I finished one year as RN student (mid 2000s) and saw truly unacceptable errors by nurses - more than I could have imagined prior to me being in nursing school - that should not happen - IV tubing falls on floor as it is being replaced and catheter/port end did not even so much as get wiped/disinfected - just hooked right up to the patient;;; changing dressing for deep foot ulcer in diabetic patient /wound care -- and nurse pulls wastebasket closer to patient mid - dressing change and does not change contaminated gloves that touched the waste basket ... others as well but don't want to write an essay here. The reality is nurses are set up to fail in this awful system we have - - they are so overworked - I cannot even imagine it now. I will repeat this again - the system needs a complete overhaul. Will this case be the force for this needed change? We finally got universal health care -- now we need universal medical error/system reasonable protections.
Thank god someone sees what I’m seeing. Was not one mistake this was many mistakes and she left the patient alone and she was trusted to train people. You’re not following protocol when you’re training people? Then thats another story all together. The poor trainee :(
Where are you? We don't have universal health care in the US
@@lauriebennett5136I have never had a nurse with me over five minutes. They have way too many patients! As if any nurse can tend to a patient for an entire hour. Yea right. That's dreaming until hospitals stop understaffed nurses and treating them like garbage.
Let’s take this back to the court. If a mistake is made in a criminal court, and a person is jailed or put to death should those that served in any capacity in that court be held criminally liable? This would balance the scales for fairness, although justice would likely be right out the window.
I remember listening you tell us about this originally and it broke my heart then. This is an awful conclusion for all parties - it actually made me sick to my stomach.
I feel so blessed to work for my hospital, and my department in particular. It’s far from perfect. We have our staffing issues, particularly in the past two years. We have burnout. But our nurse/patient ratios are far better than the national average. My department in particular has an excellent culture of teamwork and collaboration. We have excellent managers who are constantly roving the unit and offering practical help when needed- not just “great job! Here’s some pizza!” We have the systems in place to report and address safety issues. I had an adverse medication event occur once. The outcomes for the patient were fine, but it could have been bad. I was called in with the whole team that was following the patient. We went over what happened. The order sets were evaluated for appropriateness and changes were made to improve patient safety. There were no repercussions to anyone.
Our administration… well, the best that can be said is that they support patient safety and nursing because it allows us to keep our Magnet status, which gives the hospital prestige, which keeps them making money.
Where do you work?
@@MNP208 Yes, this???
Australia has an opt in “my health care record” which is accessible by everyone in the health care systems we have from the general practitioners, to both private and public hospitals. It was made “opt in” because some people don’t want their health care record shared across so many sites for fear of they private information being leaked, but for others, especially with chronic conditions, it’s a godsend.
Thank you for always having the nurse’s back, ZDogg. Thank you very much.
"Admin who set up crappy systems walk..."
Could not agree more.
Literally in tears hearing this. As you said and many of the listeners said, it could have been any of us...
Who is going to want to go into nursing after this? Unacceptable, Vanderbilt tried to sweep it under the rug
Maybe they'll just read the bottles on the medications more carefully and avoid this.
@@TheMageesa yes indeed..that’s just one of 1000’s of potential risks. Point is, mistakes happen, if criminalized the future nursing staff issues will be a bigger risk for patients
@@happycamper7815 It sounds like this was a series of mistakes. At what point does it become negligence? I think most nurses are much more attentive than this one. I know someone whose child was killed because of an error like this, and it's ruined her life. And, there's been no legal recourse for her, because 'accidents happen'. Would you be so understanding if your elevator crashed, or your house collapsed on your family?
@@TheMageesa Not sure the comparison of an elevator accident/failure or a house collapsing is the best to use in this context.
Thank you for your fantastic, honest coverage of this issue.
Every nurse at Vanderbilt needs to quit and never look back. I’ve been a nurse for a very long time and with the current environment in healthcare and society, I would never recommend to anyone at this point to become a nurse.
It’s not just healthcare. In law enforcement a person who makes a similar mistake in similar circumstances gets blasted/ fired/shunned/charged/thrown under the bus by their administration as a way to avoid/eliminate liability.
As a paramedic it always cracks me up that nursing as a career went from direct patient care with a technical level education. Now nurses have bachelors and masters (so they can take care of patients better) and most of their job is charting. So what did our healthcare system do? They hired PCTs who have a technical level of education to take care of patients again.
PCT help take care of patients. Such as assist with ADLs and such. That's is all that they do. They do not know the clinical stuff nurses know in order to properly "take care" of a patient.
@@hhc1948 I am aware but neither did nurses when nursing started. The better solution would be to hire secretaries to chart what the nurses tell them to chart and allow the nurses to be hands on.
@@SJDevenney1 nope, not better.
There were non technology safety measures in place which she did not follow even though she had a trainee with her.
How was the patients heart rate at that moment? Was the monitor going off? Did she have iv tubing twisted or a central line being tugged? I’ll wait for you answer.
Right! That's when you're supposed to be on your best behavior. She should have done everything by the book while training someone
Former lawyer here. This absolutely is negligent homicide. Negligence just means carelessness. He thinks it’s outrageous that killing a patient after half a dozen alarm bells went off was found to be carelessness?! He’s even mad she got fired. Another ZDogg outrage that when patients get killed it’s outrageous that medical professionals suffer a consequence or are criticized. Enough already.
He also says that she was convicted of reckless homicide. Recklessness and carelessness are two different standards. Recklessness is worse than carelessness. So he’s wrong. Once again he doesn’t know what he’s talking about, so we don’t know what really happened.
And yes, Vanderbilt was much worse than the nurse and should have been punished. Does NOT mean the nurse should not have been.
He is right that we do have to change a lot about medicine which kills far too many patients. But that also includes changing this culture of negligent homicide of patients being ok.
This! People need to understand there can be individual responsibilities as well as group/ organizational. I honestly don't get the outrage, and I'm a doctor. The alarm bells thing is a real systemic fatigue. But the reconstitution of vec. and the willingness to leave without monitoring are not aspects we should take lightly as a society.
Lawyer ...nuff said
My hospital just went to EPIC, we've had to override a lot and we don't do double checks on insulin like we used to. It doesn't even prompt you to put in pulse and blood pressure for blood pressure meds. I graduate in 4 weeks from nursing school and I'm legit terrified; most hospital nursing staff everywhere around me is new grads and travelers.
You can always document vitals in the nurses notes.
@@kitkat7216 true, but the point is it doesn't prompt you to enter them to give antihypertensives so uf someone doesn't check their bp and hr before giving because it doesn't pop up and they're distracted, it could go bad.
Thank you. I am frightened of hospitals. This just confirms my fears.
Totally, I'm going to do everything I can to stay healthy, never a guarantee but a reduction of risk.
I wish I could like this 100 times. Thank you for speaking about this egregious conviction.
As a LD nurse of 36 years, my heart breaks for this. The wrong people are being held accountable. I am blessed that in 91 days I retire, looking for ways to still support a very broken system. When I need healthcare my group of retired friends will be giving the care because there will be so few bedside nurses.
Happy Retirement ms. Teresa!
I'm glad there will be less patient murdering nurses
Thank you so much for making this video. I’m an icu nurse and ashamed to say but I didn’t know about this case until recently, and now with your video, I understand about it much better. As you said, it was more about the systemic error. This could be me tomorrow.
I hope the state will make the hospital take some level of responsibility.
Thank you. I wS a CNA in ICU and watched over my 30+ years as the paperless/digital record came to be. I was considering going to school to be a nurse but didn't because I saw how this system removed the nurse from the bedside and mafe them a data entry tech. Everyday there are near misses. Corporate is all about the reputation and $$$$$$ even the nonprofit organizations. I feel for this nurse and know she is being harder on herself than any prison term could be. PTSD is real even before Covid. Thank you for your support.
Nurse here….bottom line protect your license, do proper basic nursing, don’t get complaint because you have technology. Protect ur license!!!!!
I don't know. This was a MASSIVE medication error made even worse by her being an actual ICU nurse. I initially assumed she was a new grad/ or non- critical care nurse, first-day- on the job scenario. I don't understand the confusion, she literally just had to verify the name of the drug. I am an OR RN so i don't pull drugs out of a machine, but i sure as heck know how to read the label on a vial. Yes, technical issues are a pain and have the potential to complicate our job but that isn't an excuse or explanation. Criminal charges though??? Hmmmm. I would also consider the nature of the drug error that would've delivered the most agonizing death to that patient imaginable.
Agreed. Vecuronium she gave was a powder that she had to mix to give. Not liquid Versed the is draw up in a syringe quickly. Are you telling me she didnt know during mixing this medication that something was off? BS.
Thank you - my thoughts as well
ZDogg has gone off the rails, lately.
Massive error sure. From the facts I have heard from the case it was not criminal in nature. I also worry about whether anyone will report med errors in the future. It is a dangerous precedent to set. I think suggesting that nurses who administer meds double check is a great suggestion. Literally easy for us to say with perfect hindsight.
@@nszucs1 she didn't report the error until after the code and she was presented with the vecuronium vial she used. She didn't have a clue what she had done until then.
I’m an RN, I don’t think I know a single nurse who has never made a med error( big or small). It’s part of the equation being human and working in understaffed units, full of stress, and sick patients requiring ton of meds. Every one of us has en error we learn from and will remember.
Just from my knowledge of this video I think the biggest issue here is there not being a 2-party authentication process for pulling out a paralytic. Or any narcotic. I've never used a pixis system that didnt have that in place..if I were pulling out a benzo and it didnt ask me, I'd have double checked that it was the right med. I seriously worry about the implications to this nurse being convicted.. more med errors that no one will be aware of until the toxicology report on autopsy comes back. Yikes.
that's fucking scary. so how many people have you killed overt your career as an RN? how many mothers and fathers sisters and brothers are gone because you just casually give incorrect drugs without a single fuck? and then just explain it away saying... yeah brah i do this shit all the time haha giggle giggle.
I worked with an experienced nurse who accidentally set the wrong dosage on a patients pca pump. Luckily she realized something wasn’t right a little while after. The PA called a code and gave the patient narcan. Patient ended up in icu and survived, thank god. It was traumatic to witness because everything was fine one minute and went to shit the next minute. That’ll scare the shit out of you wanting to become a nurse.
@@megmc80 I was seriously contemplating going into the medical field. It was my first choice, and I went to a tech high school for it. Worked as a PCA for years as I went to school for special education. Being thrown under the bus, underpaid, overworked, physically pushed around by students, verbally attacked by students and parents etc had me ready to head back to college for a career in health care instead, but if they’re set up for failure with faulty systems and equipment and no support, I’m opting out.
Charlene Murphey won't learn anything from this
Thank you for speaking out and giving the other side of the story. People who do not work in healthcare have a hard time understanding how the system as a whole is set up. One of my co-workers used to say we ran around on bloody stumps, she was right. Nursing is not what it once was, it has been on the downward slide for years because administration has developed a new model for nursing. They talk the talk but it's called lip service. Mable Lamberson would be so disappointed today at how nursing has been veering away from patient care and loaded with charting, new systems, and big brother. Administration never worked a day in the ICU, OR and specialty floors yet they lay out the plans and dictate how the work should be accomplished in less time and with less help.
I almost died bc I was sent home after being in the ER with a PE. I had the increased lab results they look for before giving a CT and was still called a "little girl" by the doctor and mocked for reading too much Web Md.
Because I had no preexisting conditions to put me in a high risk group that he saw (I have several autoimmune disorders) he mocked me and sent me home despite the test results.
Thankfully when the morning shift of radiology came in they caught his mistake and called my husband at work, I was at home asleep on the meds he gave me to sleep. He was in tears thinking I was dead by the time he shook me awake.
All of that said I would never want him or anyone else involved to go to jail. They DID catch it at the end of the day. Could I have sued, maybe. Would I feel comfortable him losing his career because he doesn't take sick women seriously, no. We need all the doctors and nurses we can get. I did have a personal talk with him and told him what happened to me is many woman, especially WOC worst fear while in the hospital. We aren't hysterical, we aren't just overly emotional because of hormones. We are as capable as our counterparts and these misses because we are looked at as "little girls" need to stop. He cried and I cried. I am hoping it was a wake up call for him and his colleagues. Just my 2 cents.
2 nurses in our family and I just feel sick about this… error, Licence lost I see or re-training If her PTST not too bad, but jail! OMG my son needs a new career because bypassing happens all the time where he works because of insane overwork, no company investments in infrastructure, and horrible schedules and hours. Time to dump nursing ASAP
I'm a 20-year experience ICU nurse and have worked in over 25 hospitals around the country. I have probably onboarded or precepted 200 new nurses in my career. My first year of nursing I was working PRN agency in interventional radiology and doing conscious sedation on a patient having a peripheral angiogram, I had only been at this facility a handful of times, it was my first time in my career working IR and doing conscious sedation. I believe at the time we were using possibly morphine and valium, IV fluids, and I was sitting at the head of the table with the patient on the monitor a foot or two away. During the procedure, his condition and presentation started to change so I alerted the doctor and the scrubbed in IR nurse, and they proceeded to finish the angiogram and then the patient was brought to the recovery area and within a couple of minutes he was coded. I believe he ended up with a PE, or perhaps it was an MI on the table, he ended up in ICU and they withdrew care the next day. All that being said, 25,000 bedside nursing hours later, I still remember it like it was yesterday... that was just one event. I remember hundreds of events which become part of a person's mental framework, whether you're a doctor or a CNA finding a patient on the floor that just fell. 20 years ago there was no epic and hand scanning and all of that and in my example above, there was no medication error made, but that's not to say that throughout my career I haven't made any.
Just like that truck driver that got all of that uproar when his sentence came through for that horrible situation in the Colorado mountains where he lost his brakes, I find it hard to believe that nurses can't join together with their numbers, and be supported by the doctors behind them such as yourself, much appreciated by the way, and figure out some kind of way to collectively voice and move the needle in the direction of getting this poor girl off of criminal charges (I am not in disagreement necessarily of the nursing board's decision however.) This could have been me. This could have been any of us. Maybe not as high probability in today's system, but still it is not a flawless system. The reason the trucker was given consideration was because of other truckers potentially refusing to move the goods through that area. Imagine if the nurses said well we're just not going to work Icu, we're just not going to do conscious sedation, we're just going to choose types of nursing such as clinic nurse or informational technology and not put ourselves in this position. We need ICU nurses. We need nurses at 4:00 in the morning bringing patients that are unstable and near death to CAT scan. I hope just like the Dr stethoscope thing that somehow there's a movement on this as well. z dog, thanks brother and feel free to holler if there's anything else I can contribute.
Thanks for this - And it is definitely still possible. Working in an OR / procedural environments with providers who have their own meds etc... soooo much is possible. Especially if things go downhill / someone codes / too many chiefs in the room / etc... this is a scary precedent.
@MICHAEL GRAYRN Maybe as a 20 year medical professional you can help me understand this? A nurse in a critical care unit at Vanderbilt University Hospital was supposed to administer Midazolam to a 75 year old patient under her care. Instead of getting Midazolam, she couldn’t find Versed/Midazolam in the computerized medicine cabinet so she then used her override code and got out Vecuronium bromide a paralytic used during intubation and she then administered it to her patient, and didn’t monitor her properly. The patient stopped breathing and went into cardiac arrest and died.
I’ve been given twilight sedation (versed) more than half a dozen times and except for once when an Army Oral surgeon administered it, I always received that drug from an anesthesiologist, and he or she wasn’t alone in the room with me and I was being monitored. I had a heart monitor and they had resuscitation equipment right there. I don’t understand how this happened? While I feel bad for this nurse, and I don’t think she had bad intentions someone died as a result. I don’t think prosecution wasn’t out of line here. Maybe I’m wrong, but this was bad and hopefully it’s a teaching moment that people can learn from.
@@mikeharvey2748 I agree with you, the patient should have been monitored. I worked clinically as a radiology nurse for 9 years. Our staff was required to complete a competency on special considerations for the use of monitoring equipment in MRI before sedating and monitoring patients there. Non-ferrous monitoring equipment must be used. Even if the patient had been transported from the ICU on a monitor, it would probably not have been suitable for use in the MRI suite. Presumably Vanderbilt had non-ferrous monitoring equipment available, although it is not clear whether Nurse Vaught had any experience using it (yet another system issue).
As someone that came from trucking to work healthcare, don't even compare the situations.
his brakes failed, through no fault of his own. not from a negligent pre-trip inspection, not from negligent use of brakes on a downgrade.. they failed.
the nurse did not kill a patient through mechanic failure of something outside of her control. She failed to verify she was giving the proper drug, she killed a patient. She was negligent.
This situation would be completely different if the vial was labelled versed but contained vecuronium instead, but that's not what happened... is it?
@@this.is.a.username mic drop right there
The jury had barely any healthcare workers. How was that a fair judgement??? Jury and lawyers should have been comprised of people with healthcare experience.
Why? So they could exonerate her and tell nurses that it's ok to kill patients as long as they believe it was a mistake?
This is how we ended up with cops getting away with murder as long as they 'feared for their lives'.
@@this.is.a.username you obviously didn’t read the report 🙄
@@bryanh8292 your reply is irrelevant
@@this.is.a.username your whole thesis was irrelevant…
These are my thoughts as an experienced nurse. In the ICUs I worked at, it is mandatory to have two nurses check/sign off electronically prior to administering, insulin, heparin, blood products, wasting excess morphine, etc.
The system should have 💯 required a two RN check/sign off.
Where was the patient's arm band and why was it not scanned prior to medication administration?
Why and who assigned a floater nurse a trainee?
What were the nurse patient ratios that day on that unit with every nurse who worked that shift?
Perhaps, the pharmacist can be alerted when a paralysing agent is withdrawn from the automatic dispenser.
Who was the charge nurse that day on that unit and nurse supervisor?
There are 7 rights. Right patient, right drug, right route, right dose, right time, right reason, right documentation.
Shame on Vanderbilt for the way they responded to this medication error.
Whenever I see a drug I don’t know, I look it up, or call the pharmacy. 21yrs in. The alerts are there for a reason. My condolences to the family of the women that lost her life.
I agree 💯, I would have pulled out my phone when I couldn’t find it under versed to look up the generic name. It’s unbelievable an experience ICU nurse didn’t know the generic name of versed.
WOW!!!! I am so happy to FINALLY know the names, at least the first names, of the Worlds Most PERFECT Nurses. ITS AN HONOR.
@@1000lsharp not perfect, Lorrie. I also am diligently careful, but because of FEAR. I worked in NC when Duke Dr. put the wrong heart in a girl. It scared the confidence out of me. And we do get Pop Up warnings ALL THE TIME, for idiotic things. Every pixus I've ever used needed 2 nurses for Narcs. This hospital is GUILTY too. God bless everyone involved.
All nurses have made a medication error, and those who they haven't, either didn't realize it or are lying. I know I have, and I was lucky enough not to have a adverse outcome. We are all Radonda.
Your right
@Kayakdog so when you make any type of mistake, your hospital has your back 100%, been doing this too long to know that is not true. Stay in your silo
RN Med/Surg for 15 years and a Nursing Instructor (classroom and clinical setting). This week my students did not want to give medications because they were terrified! I tried to reassure them or calm them down. No change. Also, reminding them that they have been administering medications every clinical day with me since January. No change again. Some were crying. One had a mild panic attack. So, I called my DON and it was agreed to have them shadow the floor RNs for that day. I feel the nursing shortage will get worse because of this and the number of nursing students may decline in relation to this.
I hope it solidifies the importance of verifying the patient "rights." Med errors will likely still happen. Ones like this should not.
For this reason and many others I consider that choosing nursing was a big mistake. After only four years I'm throwing in the towel...Done!
There are so many problems with this case to list. But for me, you shouldn't be able to override vec ever, and if you are in a area that requires a paralytic, it should either be in a crash cart, intubation kit or the pyxis but needing to be approved. Also, the nurses in this area had to override over 30 medications that day due to communicating errors in the system. So many red flags, and one person thrown under the bus.
Nursing is such a stressful and important job for the staff to be working 12 hours shifts. No idea how anyone thinks a person can function well working 5-6 12 hour shifts in a week for long periods of time. That one factor contributes to probably around 50% of all nursing errors
@@barnabusdoyle4930 when I was deployed it was 12 plus hours everyday and multiple traumas; there was zero chance of staying on point when doing that, nurses are experiencing that level of burnout now and it is just not sustainable
So true. This nurse thanks you for your comments and insight. It could happen to any of us under current conditions. Shaming/blaming and slamming one person will not solve the present state of declining healthcare, it's so much more than that and until the real issues are confronted, mistakes like this will happen, healthcare services will continue to decline
Did anything else happen to Vanderbilt? Did they lose funding? Were they sanctioned? Anyone else fired? Their system was jacked up. They buried vital info and threw the nurse under the bus
Preach! Imagine a cop or prosecutor getting put in jail for wrongly sending someone to the death chamber or a firefighter accidentally injuring someone saving them out of a window. If that were to happen people would be on the streets with pitchforks. This woman made a terrible mistake and should probably lose her job. But unless there is intention to harm, the responsibility falls upon the institution.
I am an RN but have been out of the hospital setting for a while. I totally know that any one of us could cause an error with a horrible result. This nurse should not be convicted for this mistake, but she definitely did override various roadblocks to this error. The biggest flashing light was having a powder form of a drug that doesn't come that way. Also, patient not being monitored when in the MRI. I bet she was under stress, pressure and rushing. They need to learn from this and create better systems to prevent this. This is a tough one.