For a long time, most people were saying that most accidents were due to human error. Hed have felt his truck hitting that little car. Wolters Kluwer Health And that really should have been the end of it. Over the past 20 years, the sector has decreased its overall fatality rates by 95%. Accessed September 1, 2022. I guess the next question along those lines is if Versed is always a liquid or sometimes a powder, but I think I really dont want to play prosecuting attorney here (or on TV). The patient appeared to the nurse to be comfortable and resting with her eyes closed. After speaking with Vaught and her attorney, ANA sent a letter to the judge which would be submitted into evidence on Vaughts behalf. However, Judge Jennifer Smith, who presided over the case, did not sentence Vaught to prison. If you think the nurses had not already complained, you are wrong. Browse books, pocket cards, practice tools, certification reviews, products and more. When ratios are high, it creates a high risk for mortality, increases length of stay in hospitals and leads to preventable events like falls and infections. I guess no one likes to charge for mass murder. The prosecution of RaDonda Vaught: An ethical and legal mistake Here are the conclusions we can gain from this tragedy: Healthcare systems need to prioritize the safety of patients and the safety of their staff. This was achieved with the support of the Federal Aviation Administration, which worked with the industry to form a number of programs that monitor for and ensure compliance, like the Commercial Aviation Safety Team. As this is becoming a bit of a trend, nurses are turning in their badges. The Slate Group LLC. Your message has been successfully sent to your colleague. 2023 Mar 15;34(1):11-15. doi: 10.4037/aacnacc2023873. But they also mean bypassing the usual safety checks that would be done by a pharmacist to confirm the medication, dose, and situation before the medication was made available. Research has shown that nurse-to-patient ratios directly impact patient outcomes, including the prevalence of errors. Nicole Hester/AP RaDonda Vaught, a former Tennessee nurse convicted of two felonies for a fatal drug error, whose trial became a rallying cry for nurses fearful of the criminalization of. The site is secure. In Vaughts case, she was given vecuronium, instead of Versed, by the machine after only searching for the first two letters of the drug (VE) and choosing the first option. The family's statement did not name Myers or fellow Democratic candidate P. Danielle Nellis directly. Vaught was investigated by the nursing licensing board in the months after Murphey's death and was not at the time recommended to lose her license or be suspended. declined any disciplinary action after their investigation in 2019. [1] She was sentenced to three years' probation. As I wrote before, I think a good portion of the blame shifts to anyone who didnt monitor the patient once it was known that the wrong drug was given. In fact, the tragic incident laid bare a list of compounding issues that led to the fatal medication error, including: Vaught quickly realized she had made a mistake and reported it within roughly 20 minutes. 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And that it wasnt changed, doesnt seem to be RaDonda Vaughts fault. People, even highly skilled and dedicated professionals, make mistakes. Mistakes are a tragic but inevitable aspect of medicine, because people are an essential part of medicine. And that it wasnt changed, doesnt seem to be RaDonda Vaughts fault. But the criminal aspect of Vaughts case is unprecedented. The RaDonda Vaught Case: A Critical Conversation on Nursing Practice and Technology. I said it. She was also orienting a new nurse. "The DA's decision to charge this nurse is just one more example of how his misjudgments continue to make our community more divided and less safe. Its not just doctors who get away with it. They did. It's time for change," she wrote Friday. There are a lot of details of this case that have not made headlines, and because of that, I wanted to do a deep dive into what actually happened, an explanation of the trial, and what I think this means for our profession. When an error does happeneven a small onethe response should focus on figuring out a way to make sure it doesnt happen in the future, perhaps by scaling back hours or redesigning workflows. Presumably, those people also had opportunity to notice that the patient was not breathing. In discussion with my father (California Pharm D. for almost 45 years now with a current license), he was quite shocked about Vaughts discipline. As a resident physician, Id have to agree that the verdict isnt likely to make patient care safer for these reasons. Nurses see themselves in Vaught; our peers and colleagues and health care professionals beyond nursing see themselves in Vaught. Teri Chenot, EdD, MS, MEd, MSN, RN, CCE(ACBE), FNAP, FAAN, is Professor, Keigwin School of Nursing, and Chapter Leader/Faculty Advisor, Institute for Healthcare Improvement Open School Chapter and Brooks Rehabilitation College of Healthcare Sciences, Jacksonville University, Florida. What it comes down to, though, is yes, she is being made a scapegoat. You never want people to casually bypass a safeguard / control system. Photo by Ante Samarzija on Unsplash. Decades of safety research demonstrate that a punitive approach to healthcare errors drives problems into the shadows and decreases patient safety. Pennsylvania Patient Safety Authority. Most hospital policies require the nurse to monitor the patient when being given a sedative, though some allow for the sedative to be given, the patient to be monitored for a short period of time (5 minutes or more), then sent to testing. Affirmative action hasnt made up for centuries of racial discrimination, Winnetka taking a closer look at billionaires planned land swap near beach popular with dog owners. Vaught realized that she had given the wrong medication and immediately reported what she had done. It is argued that the prosecution of Ms. Vaught was wrong; however, in contrast to some commentators, it is argued that the wrongness of Ms. Vaught's prosecution did not stem from its effects on patient safety, but from the fact that the charges, in this case, were legally and ethically unjustified in themselves. Why it matters: The health care industry fuels Nashville's economy. I have personally seen patients go unmonitored who shouldnt (imho) and patients go monitored when thats a gross overestimation of their acuity. doi: 10.1016/j.bja.2022.05.023. In the wake of the verdict, some nurses have quit the profession altogether. Per those communications, we drafted a letter for submission to the court as evidence through her counsel. Edited to add: It will be interesting to see how hospitals respond to this. ANA supports a full and confidential peer review process in which errors can be examined and system improvements and corrective action plans can be established. J Clin Psychiatry. While these machines are intended to keep patients safe, they also can be maddeningly restrictive at times. Then its just bad policy. In this case, weve simply punished a single worker when we could have instead encouraged institutions to improve their systems and processes so that future patients dont suffer from similar errors. The truck just kept going, to the terror of the occupants of the little car. It is so rare that when googling, I came across only one article which references NYT back from the 90s. and constant technical problems caused by an ongoing overhaul of the hospitals electronic health records system which was slow and incomplete. Would you like email updates of new search results? Anesthesia Patient Safety Foundation is part of the Non-Profit & Charitable Organizations industry, and located in Minnesota, United States. In the first formal statement since the trial, Murphey's daughter-in-law Chandra Murphey echoed his sentiments. The single biggest mistake to me, because it was likely more unrecoverable than the others, was the no monitoring thing while transporting the patient. In defense of the doctors and protocol, it is not uncommon for patients (even monitored ones) to be unmonitorex for 10-30min for a test. TikTok (that crazy Chinese app) is full of nurses with stories that would shock you. You will receive an email with a link to set a new password. Civilian Medical Podcast on Apple Podcasts Did NASCAR pay enough to use Grant Park, downtown streets? I had an interesting experience years ago. Structures should include full and confidential peer review processes to examine errors, deploy system improvements, and establish corrective action plans. Murphey died in the hospital two days later. Even with breaks. If a provider simply cut corners, then that individual should be sanctioned, but in this particular case, the root cause was multifactorial. Malpractice insurance does not cover criminal charges and nurses do not make enough to retain an attorney just in case a DA determines that they need an easy win to pad their prosecution record. Nurses, physicians, pharmacists, and other practitioners regularly have their licenses suspended or removed given various grievances. To be sure, working in health care comes with great responsibility. Then its just bad policy. Images via Wavebreakmedia/iStock/Getty Images Plus and Olga Siletskaya/Moment via Getty Images Plus. As my mother asked me countless times in my childhood How do you know you dont like it if you havent tried it?. The context of Vaughts mistake and the pressured environment in which Vaught found herself feels shockingly normal to me, as someone who has only ever operated in a health care system that has arguably collapsed under the weight of the pandemic. Nurses and other health-care workers across the country let out a collective gasp when we learned of the verdict, in part because we all know that we couldve been RaDonda Vaught. Keywords: This is also part of the problem here. Thankfully, the patient didnt suffer any adverse consequences. I think is will answer some of your questions. RaDonda Vaught, medication safety, and the profession of pharmacy Afflictions like burnout that can decrease job performance are increasingly just part of the description of being a health care worker. Accessed September 1, 2022. The investigation must look at the systematic approach as well as the individual caretakers actions. The only time where a worker should be punished for an error like this is when the worker made the situation worse than another worker making the same mistake. What this case illustrates to me, as someone who has only worked as a physician in COVID times, is how dysfunctional our health system was just a few years agoand the amount of work we need to do to fix it even as COVID recedes to be more manageable. On December 27 at 1 a.m., Charelene Murphey was declared dead. As we hobble out of the pandemic, Vaught and her patients story should compel us all to build a better health care system for the futurenot further punish someone who has left the profession. Her husband and she own a hunting business. And why wasnt it changed if it was known that she was given the wrong drug? Use this tool Tammy Spencer, DNP, RN, CNE, ACNS-BC, CCNS, is Associate Professor and Assistant Dean of Undergraduate Program, University of Colorado College of Nursing, and Clinical Nurse, Post Anesthesia Care Unit, University of Colorado Hospital, Aurora. Accessed September 1, 2022. Jane Barnsteiner, PhD, RN, FAAN, is Professor Emerita, University of Pennsylvania School of Nursing, and Editor, Research and Quality Improvement, The American Journal of Nursing. The RaDonda Vaught trial has ended. The Case of Nurse RaDonda Vaught - Health eCareers We otherwise will continue to stretch health care workers to the point of producing horrific errors, left unchecked, that leave patients paying the ultimate price. After the verdict was announced, she told reporters, Nothing that the district attorney said yesterday is worse than anything that Ive said to myself. While her sense of guilt is understandable, her legal punishment only serves to obscure the conditions that make such medical errors possible. About all the hospital could do was pay money, which they did. I read a lot of professional assessments of potential malpractice cases because I proofread for a friend who is a cardiac/thoracic surgeon and is often called upon to render a professional opinion. The medication error occurred on Dec. 26, 2017, when she was scheduled for a PET scan but was found to be incapable of lying still long enough to endure the study. A few years ago, a nurse I was working with made the same mistake as Hiatt, with a different drug. All rights reserved. maybe you didnt want to know. I found this article helpful in making sense of what all happened when. Even before former Nashville nurse RaDonda Vaught was convicted in the death of a patient, medical professionals were concerned about the chilling effect a guilty verdict could have in the . Nurses everywhere are not just looking at Vaughts scenario in isolation. But nearly a year after the event, an anonymous tip, a surprise inspection and state and federal investigations led to threatened sanctions for VUMC and a a criminal indictment for Vaught. If were prosecuting medical mistakes, someone needs to contact Andrew Cuomo. Vaught is quoted as saying that at the time of Murpheys death. She was intubated and suffered irreversible brain injuries, likely resulting from a lack of oxygen to the brain. RaDonda Vaught, 38, was indicted in 2019 on two charges, reckless homicide and impaired adult abuse, in the death of Charlene Murphey at VUMC. RaDonda Vaught sentenced to three years probation on a diverted Bookshelf Out here, Vandys where you go when you need serious medical attention. Catastrophic errors are often the result of many factors, and individuals should be able to safely report errors or system inadequacies. Spend some released statements in support of Radonda. Once identified, all eyes turned to her. The jury found Vaught, a former nurse, guilty of. Patient safety is at the forefront of our curriculum. document.getElementById( "ak_js_1" ).setAttribute( "value", ( new Date() ).getTime() ); document.getElementById( "ak_js_2" ).setAttribute( "value", ( new Date() ).getTime() ); *By submitting your e-mail, you are opting in to receiving information from Healthcom Media and Affiliates. While working in this role, Vaught was also tasked with training a nursing student. Top Republicans are gearing up to investigate the Hunter Biden case. In any case, in multiple instances throughout the report, Murpheys medical team expressed concern that her PET scan could be abruptly rescheduled if she werent quickly given the medication she needed for her anxiety. People are *exhausted*. The RaDonda Vaught homicide case was an American legal trial in which former Vanderbilt University Medical Center nurse RaDonda Vaught was convicted of criminally negligent homicide and impaired adult abuse after she mistakenly administered the wrong medication that killed a patient in 2017. Facts - Nurse RaDonda Vaught became employed by Vanderbilt in October 2015. Even the ISMP (Institute for Safe Medication Practices) President was quoted in an article regarding the various systems errors that had to occur to even allow Vaught to make the error. Vaught, a former Vanderbilt nurse, was found guilty in March of two charges, criminally negligent homicide and abuse of an . Tennessee Department of Health. Why do I get the feeling it will be even more CYA and as usual more useless protocols and classes. Somewhat related: Radonda Vaught is also being charged with perjury for incorrectly filling out paperwork to receive two rifles. Before I certainly hope it is. Check out our new podcast for insight and analysis about the latest patient safety and quality issues! Once identified, all eyes turned to her. Even if the doctor thought that was okay before, it should have been changed. They wanted justice for Charlene Murphey and that is what our office achieved for them," Funk wrote. Yes, Vaught was the one who ultimately administered the wrong medication. Impossible standards for patient care. 7 April 2022 The WSWS is organizing the working class to defend former Vanderbilt nurse RaDonda Vaught and all health care workers against victimization for the crisis of the for-profit health. (Stephanie Amador/AP) Last month, RaDonda Vaught, a nurse in Tennessee, was found guilty of . Part of my role on the nursing faculty at Rush University is to prepare the very nurses who are being added to the work force to address the worsening shortage. Hank from the Internet(View Comment):Lets just say that Im not heartened by the notion that medication mistakes happen all the time. But someone wanted to blame a person, and the hospital/administration threw her under the bus, or to the wolves, or whatever the kids say now. Many health care workersparticularly nurseswork grueling hours while facing distractions, like alarm fatigue, that contribute to making errors. And one should certainly be held responsible for overlooking them. Mary Jean Schumann, DNP, MBA, RN, CPNP-PC, FAAN, is Chair, Nursing Alliance for Quality Care; Director, DNP Program Health Policy Track; and Associate Professor, The George Washington University School of Nursing, Washington, DC. Please enter your email address or username. RaDonda Vaught - .. - Anesthesia Patient Safety Foundation - ZoomInfo Journal for Nurses in Professional Development38(6):329-332, November/December 2022. 2022 Nov-Dec 01;38(6):329-332. doi: 10.1097/NND.0000000000000945. Many health care workers and institutions have questioned whether the arrest and conviction were the right calls. The American Nurses Association has highlighted the nurse staffing crisis and outlined proposals for safe patient ratios to be incorporated in state and federal legislation. The NPR story mentioned that vecuronium is a powder. I would not sweat it. You have to dissolve it in distilled water first. The RaDonda Vaught Case: A Critical Conversation on Nursing - PubMed As a hospital pharmacy technician (lead IV tech), none of my mistakes ever made it out of the pharmacy, and I made precious few mistakes. The Civilian Medical Podcast aims to prepare and educate you for the day you hope never comes. Health systems should be designed to spot and address those errors before bad outcomes happen. Vaught's attorney Peter Strianse told The Tennessean on Friday that his client was uninterested in any plea discussions that arose throughout the case. Because with these guidelines, there isnt enough time in the day for it. Let me be clear: Vaughts error was egregious and its right that she lost her nursing license. (The patient) got such a small dose, and he/she was anxious about the test, so we cant say it contributed to his/her demise.. Nurse RaDonda Vaught faces criminal trial for medical error - NPR She went into the medication-dispensing machine and attempted to type in the brand name of the medicine. Accessed September 1, 2022. Photo illustration by Slate. No time for personal care. For more information, please refer to our Privacy Policy. MEDIA CONTACTS: Shannon McClendon, shannon.mcclendon@ana.org Keziah Proctor, keziah.proctor@ana.org SILVER SPRING, MD - Former Vanderbilt University Medical Center nurse RaDonda Vaught has been sentenced to three years of probation after a jury convicted her of criminally negligent homicide and impaired adult abuse for mistakenly administering the wrong medication that resulted in the death of . And how is the malpractice as unambiguous as this one? Two people inside two separate cars fired shots in the 1600 block of West Howard Street, police said. The error was, A Vanderbilt hospital doctor indicated that. This article was published more than1 year ago. Some worry the decision to try the case in criminal court, instead of by professional regulatory boards, could make people fearful of reporting mistakes and down the road lead to issues with patient safety if broken systems aren't caught. If we want to eliminate all errors, we would have to eradicate all humans from health care. Though Ive read many such assessments, Ive rarely encountered an example of malpractice as apparently unambiguous as this one, though perhaps that has to do with the inherent variability of critical surgery compared to the obviousness of this particular error. To start off, it isnt clear to me why Murphey needed a PET scan done so quickly while hospitalized; PET scans generally require significant preparation best done outside of a hospital, and are rarely urgent. The RaDonda Vaught Case: A Critical Conversation on Nursing Practice and Technology AACN Adv Crit Care. But RaDonda Vaught is one of the only, if not THE only, people who could be specifically identified. Miss Manners: Is it tacky to bring gifts with sons school application? Four years ago, inside the most prestigious hospital in Tennessee, nurse RaDonda Vaught withdrew a vial from an electronic medication cabinet, administered the drug to a patient and somehow. Studies completed prior to the great resignation estimated there will be a shortage of over 500,000 nurses by 2030. The health care industry recognizes the gravity of medical errors and has made efforts to determine solutions to reduce inevitable mistakes made by humans who deliver care. In fact, leading up to the sentencing hearing, ANA was in communication with Vaught and her attorney to discuss the best ways for ANA to provide support to Vaught in the specific context of sentencing. Smith pointed out thatVaught was transparent in reporting the error; she showed remorse; her mistake was unintentional; the incident was not done in malice; and she had no intent to do harm. Recently, nurses have rallied around popular social media influencers to demand safe staffing. The real issue here seems to be the conditions at work that caused her to grab vecuronium instead of Versed in the first place. A lead investigator in the criminal case against former Tennessee nurse RaDonda Vaught testified Wednesday that state investigators found Vanderbilt University Medical Center had a "heavy. But it could also be a cautionary tale. Just think what the Left would have liked to prosecute Trump for, they would have loved to charge him with murder for everyone who died of/with covid during his time. Unable to load your collection due to an error, Unable to load your delegates due to an error. As was policy at the time and while precepting a trainee, Radonda overrode their Pyxis machine to grab versed (a sedative agent) and instead grabbed vecuronium (a paralytic agent). That is: During an urgent situation, involving a patient she was unfamiliar with, she was multitasking. Contemp Nurse. Just Culture encourages asking What went wrong? rather than Who wronged?, This movement of transparency rose from a landmark report put out by the Institute of Medicine in 1999, called To Err is Human. The document, according to its creators, breaks the silence that has surrounded medical errors and their consequence but not by pointing fingers at caring health care professionals who make honest mistakes. The authors argued that blaming an individual does little to make the system safer and prevent someone else from committing the same error.. Radonda Vaught Is a Scapegoat | Ricochet Last month, a jury in Nashville found Vaught guilty of negligent homicide and gross neglect of an impaired adult. Vaught was sentenced Friday to serve three years probation for her involvement in the death of a Nashville woman five years ago. And that really should have been the end of it. And why wasnt it changed if it was known that she was given the wrong drug? Instead, she called for a change in the U.S. healthcare industrys approach to safety. And at the end of the day, we know the math. From decades of research, we know medical errors are bound to happen. I assume a mistake of this magnitude is relatively rare. Seems to me it should have included a lot more, without having to go to other referenced articles. The procedure requires the patient to be injected with a radioactive medication, followed by a timed series of images with either a CT or an MRI machine. 1 Following the conviction, there was an avalanche of reactions from both within and outside of the nursing profession. I dont think I would wonder or worry about a nurse possibly making a mistake, I would be concerned that an earlier decision by a doctor would not be overruled even if the situation has clearly changed. Your email address will not be published. The case has ignited debate among the medical community. If you thought nursing was in trouble before (projected healthcare worker losses in the next 5 years . "When the Tennessee Bureau of Investigation brought this case to me, I found out this was not about one mistake," Funk wrote in a statement released Thursday afternoon. Slate is published by The Slate Your nurses training shouldnt be. A week after a former Nashville nurse was convicted in the death of a patient, the uproar over the fallout has spilled into the upcoming district attorney race. What it comes down to, though, is yes, she is being made a scapegoat. Careers. When major medical errors occur, accredited third-party organizations like The Joint Commission, the Centers for Medicare & Medicaid Services, or the Agency for Healthcare Research and Quality should routinely conduct independent investigations. If were prosecuting medical mistakes, someone needs to contact Andrew Cuomo. In the hours after the verdict, candidate Sara Beth Myers issued a statement calling Vaught's actions "civil medical malpractice" that should not have been handled in criminal court. Supporters for Vaught have rallied on social media platforms like Twitter and TikTok, while a petition circulating online calling for clemency has already gained more than 200,000 signatures. The prosecution and ultimate conviction of nurse RaDonda Vaught is both a warning and a call to action for pharmacists and the profession of pharmacy. Punishing nurses like RaDonda Vaught may perpetuate medical problems The diversion of the sentence means Ms. Vaught can see the charges wiped from her record, provided she meets the terms of her probation. RaDonda Vaught: Key players in the case against former Nashville nurse, Vaught: RaDonda Vaught: The former Nashville nurse faces years in prison after conviction. Become a member to join the conversation. Lusk C, DeForest E, Segarra G, Neyens DM, Abernathy JH 3rd, Catchpole K. Br J Anaesth. There should be an industrywide effort to create and instill a culture of safety that spans from top health system decision-makers to the newest staff members. If you want to eliminate adverse events, you need to redesign the system. Nurses everywhere are second-guessing their choices in career. She typed in "V-E" to the system and took out Vecuronium instead of Versed, ignoring warning messages and a large label on the medication vial reading "Warning: Paralyzing . Vaught faces up to eight . Original Document (PDF) . The verdict: Ex-nurse RaDonda Vaught found guilty on two charges in death of patient. RaDonda Vaught DA Discovery. Vanderbilt nurse RaDonda Vaught's guilty verdict and 'Just Culture'
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