Unless you’ve been under a rock in the last week, or have your head down in your pandemic hole because you’re still working all the hours that are, a jury found a nurse guilty of criminally negligent homicide last week for a medication error. The medication error that sadly ended in a fatality.
Most nurses that I know, and I know a lot, are in shock.
At any time that could be us on that stand, in that courtroom. Receiving a guilty verdict for something that should never gone to trial.
I can guarantee that RaDonda Vaught did not become a nurse to kill a patient. All of us live with the fear that this could happen at any time. We work with powerful, dangerous medications every day.
We, as nurses, did not become a nurse to be the scapegoat for the hospital’s system bad policies. Or to be convicted for the swiss cheese effect. This is where the system of errors
This will have a chilling effect on healthcare.
On nurses.
Errors will still continue. That’s what makes them errors. They are unintended. Hospitals will still have bad policies that do not protect the nurse.
Nurses will take extra care around medication errors
Let us pretend that there is a patient S. S for seizure. He feels terrible and goes to the ER. Patient S is not a patient not in the system because he was new to the hospital he presented at and normally went to the other hospital system in town. Patient S promptly had a seizure. Because he was not in the system, he was not in the Pyxis (which is the medication dispensing unit). And they were unable to get medication to help him. Because that was an override medication. No nurse is going to override for that medication after this. Because RaDonda Vaught’s story teaches us that we can go to jail for that. Could he die from a seizure? Absolutely. Could he die from not receiving the Valium that would stop the seizure? Yes. No nurse I’ve talked to will override the medication now.
No one.
Will Patient S receive substandard care for not being in the system? Probably. Until all the systems kick into place to release the medication under his name.
You can’t have it both ways. Horrible that Patient S is suffering. Horrible that the nurse is powerless to stop it.
Here’s what I know.
Nurse RaDonda Vaught was stripped of her nursing license in July 2021. After the board of nursing declined to rescind it before.
She was convicted of criminally negligent homicide in the death of Charlene Murphey March 25, 2022. Something the family didn’t even want.
She has yet to be sentenced to jail.
She lives knowing everyday that she caused the death of a patient.
Was she stupid for overriding the medication?
Yes.
Was she stupid for not looking at the medication vial? At the paralytic warning sticker on the vial? For not realizing that the vecuronium was in powder form and needed to be reconciled? Unlike versed which is a liquid.
Yes.
Was a criminal conviction warranted?
No.
Should it even have been sought?
Hell, no.
A root cause analysis should have been done at the hospital level. Changes could have been made. Improvements could have been made. And the patients kept safer.
The system in that hospital allowed this to happen. She reported it right away. The hospital did not. The hospital has not said much about the entire thing.
And the ADA said that “RaDonda Vaught PROBABLY didn’t intend to kill (the patient) but she made a knowing choice.” The word choice of ‘probably’ makes me mad.
So very mad.
None of us became nurses to PROBABLY take care of patients. No. Full stop. We became nurses to take care of patients to the best of our ability.
Like a human. Taking care of a human patient.
Nurses are people too.
District Attorney for Nashville, TN is Glenn Funk. He is up for what purports to be a tough re-election.
He needed a win.
That’s how I see it.
Me, I wonder why the medication was in the radiology department AT ALL.
This could be happening to any of us.
Dispatches from the Evening Shift 