Nurse Guilty of Homicide After Med Error.

[sas5814]

I have been following this story for a while and today the verdict came in. A cascade of errors resulted in the patient's death:

https://news.yahoo.com/former-nurse-guilty-homicide-medication-175806261.html

 

Lots to unpack here. Lots of mistakes. Homocide? That's a tough call. I'll be interested in the sentence.

[rev ronin]

6 minutes ago, sas5814 said:

I have been following this story for a while and today the verdict came in. A cascade of errors resulted in the patient's death:

https://news.yahoo.com/former-nurse-guilty-homicide-medication-175806261.html

 

Lots to unpack here. Lots of mistakes. Homocide? That's a tough call. I'll be interested in the sentence.

Homicide is a given: the actions of one human killed another.  There was obviously no intent to kill, so not murder.  The patient was not a threat to the nurse, so not justifiable homicide...

That leaves excusable homicide (a mistake which no one could have reasonably expected to cause death) or manslaughter (a bad action which had the foreseeable consequence that someone died), which is also known as criminally negligent homicide--the actual conviction in this case.

[sas5814]

Yea I get that. I had to talk a lady off the metaphorical ledge because an executed prisoner (by the state) was ruled a homicide...which of course it was.

I guess my question is how many errors does it take to become a criminal action?

Edited March 25, 2022 by sas5814

[rev ronin]

I've been following the case, and it's clear that there are errors to go around.  Vanderbilt is throwing her under the bus, but really what she's guilty of is working too fast in a system that prioritized speed over accuracy.  Alarm fatigue and normalization of deviant behavior also clearly played roles.

We hear weekly here of PAs asked to let scribes close charts (hell no) or nurses alter dosing or any number of other no-nos.  These things happen, and bad stuff also happens, likely in a power-law distribution (for every death there are probably 10 serious reactions, for every 10 serious reactions there are probably 10+ minor reactions, for every minor reaction there are probably 10+ near misses that a vigilant Pharmacist caught...)

I am kind of a fan of the way she's taken responsibility from the beginning, but at the same time pointed fingers at the system that prompted such a catastrophic failure. ZDoggMD has had some good commentary on this case; I'm pretty sure he's going to have a pretty PO'ed monologue about it this weekend.

[FiremedicMike]

IMHO - this wasn't a simple med error.  This was a series of bad decisions and generalized medical incompetence that culminated in a patient's death.  Reconstituting vec is a multi-step process and alarm bells should have been clanging, remember she was an experienced ICU nurse.  The fact that her patient/med scanner wasn't working should have also been a clue for her to double check the MAR and the vial.  

On top of that, the versed was being given to reduce agitation for an MRI.  Versed and Vec both kick in pretty quick, and if she would have stayed to reassess for desired effect (in the case of versed, decreased agitation) she would have noticed the apnea and complete lack of patient movement.  She could have called the code and bagged the patient who could have then been intubated and managed until the vec wore off.

As for the rabble on how this destroys the integrity of just culture - the fact is that there comes a point where simply admitting your mistake doesn't mean you are no longer responsible for it.  The best comparison is to that of a drunk driver.  He went out with friends, 1 beer turned into 6 and then a few shots because he was having a good time with old friends.  He gets into his car and crashes into grandpa and kills him, which he definitely didn't intend to happen in the first place.  He doesn't get to say "man I'm so sorry I got drunk and killed grandpa, I admit my responsibility" and then get sent home with a "thanks for standing up, we hope you learned from this and it won't happen again".

 

At the end of the day, there is a point where medical errors transition from simple mistakes to reckless/negligent behavior.  This was apparently that point.

Edited March 27, 2022 by FiremedicMike

[rev ronin]

I somewhat disagree. Nurse managers are very big on "doing everything right" and "not cutting corners" while simultaneously assigning more work than is reasonable. You don't get fired for cutting corners unless you're caught cutting corners.  You will get fired for being too slow.

There is no way an 'override' should have been necessary on a regular basis for Pixis access: that completely negates the safety aspect, but doesn't really get people thinking "By doing an override, I own everything here, because it's NOT going to keep me from getting the wrong thing."

In any IT migration, there should be a bunch of abort conditions that trigger a rollback, reset, and rescheduling of the update. The loss of patient med safety should have been one of them. The IT service at Vanderbilt removed a key safety feature by their ineptitude, and someone in management signed off on that as OK.

Why was Vec in the main Radiology Pixis in the first place? Standardization?  Vec in hospitals should be in anesthesia and crash carts exclusively, should it not?

The hospital filed the death certificate AS A NATURAL DEATH, not mentioning the medication error, AFTER they had fired Vaught for that fatal error. Intentional falsification of a death record to hide wrongdoing (or even potential wrongdoing) should be a felony. Where's the practitioner who signed off on the death? Why isn't he or she on trial?

Vaught had a trainee with her at the time, and was explaining the override system. 

There are a cascade of errors, both personal and systemic, but also clearly premeditated bad actions by the hospital. Vanderbilt should be on the hook for crimes related to this, regardless of the settlement and gag order with the family of the deceased.

https://www.npr.org/sections/health-shots/2022/03/24/1088397359/in-nurses-trial-witness-says-hospital-bears-heavy-responsibility-for-patient-dea

A woman died screami... no, wait, she couldn't. A woman died paralyzed, unable to move or breathe, in the tube she was already afraid of.  For the minute or three before she lost consciousness, she was literally tortured.  Vaught will have to live with that for the rest of her life, as any conscientious human will, but there's more than enough guilt to go around.

[FiremedicMike]

I’ll certainly agree that Vanderbilt had set up a terrible system where failure was likely, but -

She was the one who grabbed the random vial and just assumed it was what she wanted.

She was the one at the bedside who didn’t double check (again).  The implication here is that she just drew the entire vial and pushed it, because if she had checked to verify the concentration to figure her volume, she would have once again seen vecuronium

She was the one who pushed the med and failed to reassess.

I didn’t know she had a trainee.  In my eyes this makes it even worse for two reasons

1.  She had been previously identified as being an above average nurse capable of training new people

2. She was training a new employee on abysmal nursing practice.

 

And not to dwell on the drunk driving examples, but we don’t hold the 7/11 responsible for making beer so easy to get nor the car for being so easy to put in drive, we blame the drunk driver for making all of those decisions at once and hurting someone..

[ventana]

Linking in another learning moment.  
 

first out of school I always felt awkward always asking every patient if the had any allergies before I wrote a Med (before days of EMR).  Learned fairly quickly that this is SOP and you just did it every single time.  
now EMR are here.  So much bull crap. You forget the simple thing of “are you allergic to this medicine”    I still do it out of habit, but how many new HCP do not because they never had to write a script or sift through paper charts. 
maybe computers are part of the cause??

[rev ronin]

I say to patients so many times per day "I know it's in the computer somewhere, but asking you is faster than looking it up."

[mgriffiths]

On 3/27/2022 at 11:30 PM, rev ronin said:

I say to patients so many times per day "I know it's in the computer somewhere, but asking you is faster than looking it up."

I've said that...but I've also said, I don't trust the computer...the number of chart errors I've seen is astonishing.

One that is incredibly simple and I see it multiple times per day in orthopedics:

Patient has listed allergy to codeine, but would like a pain medication for their fracture, post-operative care, etc.  When I ask about it they respond, "Oh it just makes me nauseous.  It's fine."  THEN WHY IS IT LISTED AS AN ALLERGY!?!?!?!  Does the person who put this in the chart as an allergy without confirming an actual allergy realize how many more clicks it will take me to prescribe the medication?  It's infuriating.

But to get back to topic at hand...I think it is obvious that this nurse bears responsibility for her actions.  Does that mean the charges brought against her and the resulting sentence are appropriate?  I don't know.  But absolutely she bears responsibility.

Much more importantly is that Vanderbilt and its administrators bear a significantly greater responsibility...and because they are able to hide behind the faceless organization there will be zero change to how healthcare is performed in this country as a result of this unfortunate tragedy.  So many systemic issues within our healthcare system contributed to this tragedy and NONE of them will be addressed.  None of them will even be addressed within Vanderbilt because everything is falling on this nurse and in a few days/weeks time everyone will have moved on.

[sas5814]

9 hours ago, mgriffiths said:

Much more importantly is that Vanderbilt and its administrators bear a significantly greater responsibility...and because they are able to hide behind the faceless organization there will be zero change to how healthcare is performed in this country as a result of this unfortunate tragedy.  So many systemic issues within our healthcare system contributed to this tragedy and NONE of them will be addressed.  None of them will even be addressed within Vanderbilt because everything is falling on this nurse and in a few days/weeks time everyone will have moved on.

I wrote a position paper 2 years ago, adopted by PAFT,  called "Shared Liability and Responsibility" and this case is the perfect example. I opined that, when a medical professional is harmed by a policy, they should sue the individual administrators responsible... personally. Person to person. If you yank them out from under the protective umbrella of the organization and give them responsibility there would be far fewer bad and dangerous policies.

[rev ronin]

3 hours ago, sas5814 said:

I wrote a position paper 2 years ago, adopted by PAFT,  called "Shared Liability and Responsibility" and this case is the perfect example. I opined that, when a medical professional is harmed by a policy, they should sue the individual administrators responsible... personally. Person to person. If you yank them out from under the protective umbrella of the organization and give them responsibility there would be far fewer bad and dangerous policies.

Is it still on the new/redesigned website?

[sas5814]

23 minutes ago, rev ronin said:

Is it still on the new/redesigned website?

I think so. Kris was looking for it the other day and published it with the article in PAFT FB groups. I don't know if its up on the new website or not

 

[Cideous]

But homicide? Like go to jail homicide???  I mean damn, give me a break.

[iconic]

This would not have happened in any male-dominated profession. Quite frankly, I am scared who is gonna want to stay in nursing after this 

[ventana]

12 hours ago, iconic said:

This would not have happened in any male-dominated profession. Quite frankly, I am scared who is gonna want to stay in nursing after this 

Those sitting on fence of leaving have one more reason to go

 

 

the way salary is heading I think I should look at becoming an RN. 

[iconic]

Here's another one:

https://www.inquirer.com/news/nation-world/mcmaster-father-fatal-fall-nurse-trump-philadelphia-20220329.html

I blame lawyers who have ruined healthcare

[polarbebe]

https://www.nbc4i.com/news/local-news/lewis-center/former-lewis-center-nurse-accused-of-killing-resident-not-required-to-post-bail/amp/
 

RN facing charges of reckless homicide and involuntary manslaughter for forgetting to replace a trach collar providing oxygen.