What Do You Think? –A Nurse Is Prosecuted For A Fatal Medical Mistake

No doubt you've seen the headlines about a former nurse at Vanderbilt University Medical Center that was arrested and charged with reckless homicide and abuse in February for making a medical mistake that resulted in an elderly patient's death.

The nurse pleaded not guilty. The district attorney's decision to charge Vaught comes after both the Tennessee Department of Health and the federal Centers for Medicare and Medicaid Services investigated the incident.

According to news reports, the nurse was trying to give the patient a dose of an anti-anxiety medication, midazolam (brand name Versed), before an imaging scan during a December 2017 hospital stay. Instead the nurse gave the patient vecuronium, a paralytic drug used during anesthesia that had the same first two letters. The patient died in an intensive care unit the following day.

The Nashville District Attorney's office told the Tennessean it made the decision to bring criminal charges against the nurse specifically because she administered the fatal medication after overriding the safety mechanism in the dispensing machine.

Criminal charges for a medical error are unusual, patient safety experts say. Some are voicing concern that the move sets a precedent that may actually make hospitals less safe by making people hesitant to report errors.

Medical errors are common. Some researchers estimate they're the third leading cause of death in the United States. And many in the patient safety community say they don't understand what prompted the DA's office to prosecute this case in particular.

The American Nurses Association issued a statement criticizing the charges, saying that "the criminalization of medical errors could have a chilling effect" on health care workers' willingness to report errors.

We want to hear your thoughts on this. What do you think? Does this make medicine safer or will it ultimately have a negative impact on health care workers' willingness to report errors? Share your thoughts in the comments section below and click here to read more information on the case.

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Debbie Mucci

Huge disconnect here. In no way shape or form should this nurse have had the ability to cause this terrible accident. Where were the safeguards? How in the world did the hospital allow a floor nurse (and not- at least- a CRNA or specially trained nurse) to: #1.) Allow or Expect the nurse to administer either med? #2.) Provide any type of access to the meds? #3.) NOT take responsibility for THEIR part in this? How could there be access to either of these medications? I’ve been an RN for over 33+ years. When, “back in the day” in critical… Read more »

Jennifer

This is totally ridiculous. Nurses always take the fall for everything and are always thrown under the bus (and sometimes by other nurses, they eat their young you know)! This sets a dangerous precedent that we can never come back from. Ugh.

EVETTE WILLIAMS RN

Yes, a mistake was made. Why was it made we may never have the answer. However, the hospital should also share the responsibility. Obviously there was no malicious or criminal intent. Nurses do work under intense pressure, and when the shoe is not on your feet you can always have the answer to how and why. My prayers are with this nurse who has to carry such a burden of guilt.

BH

Question: A person goes into flash pulmonary edema. Do I override the Pyxis for Lasix on a MDs verbal/telephone order, or do I wait 15-45 minutes for the med to be verified by the Pharmacist and made available in the Pyxis without overriding? SBP 200, RR 36 wet and crackly lung sounds. My waiting for pulling the med properly may cause the death of my patient. Granted lasix is neither a paralytic or sedation drug. There were also many other MISTAKES. I do not know the circumstances, of why and how this many errors took place. As a brand new… Read more »

C. Shoaf, RN

I am just shocked over this story. I cannot believe a nurse gave this medication. So, she didn’t look at the bottle, or she didn’t know the difference? Those meds don’t even sound the same and don’t come in the same form. I am trying so hard to understand this nurse. I always give nurses the benefit of the doubt. But I just can’t with this situation. I’ve never seen Versed given for a scan either. The override was completely wrong but even taking that out of the equation, did she not read the darn bottle? Didn’t she have to… Read more »

CC Martin, MSN, CRNA

I am a CRNA! Read your labels CAREFULLY! Sadly I do believe the nurse is guilty. We are held to high expectations and thus must pay for our mistakes like the rest of the world!!

Mel

I really feel bad about the Nurse- yes she should definitely have done the 5 Rs. But as others had stated/ why were these medications stocked in those areas? And why Versed ordered for a scan? So many factors- but as usual it’s the Nurse who gets thrown under a bus- the hospital administration -and many hospitals elsewhere, treat nurses like disposable resources. There isn’t much respect. Lack of respect and lack of power = poor treatment of nurses. That is why the Healthy Work Environment initiative is being pushed by the AACN. HWE=patient safety. As for the override- there… Read more »

Sheila D. Nipper

This should not be punished in the criminal justice system. If I still did floor nursing I would be extremely reluctant to report errors if that’s the new trend. Actually I would be extremely reluctant to work as a nurse.

RA

As a Nurse, since 2005, we can all relate in some form or fashion to making a mistake, we are human & not perfect, but what we must ALWAYS consider is that there are checks & balances in place for a particular reason. I do not believe there is any excuse for overriding a system that is in place to protect patients & providers of healthcare. No matter how many hours we’ve worked or how tired we are, we simply can’t override those checks & balance systems, because when we do, we are taking full responsibility for our individual actions… Read more »

th

as a crna this is quite confusing as vecuronium has to be mixed it comes as a powder where versed does not i know we all make mistakes but there is something wrong with this situation

Kathy chaney

I am a nurse with 3 decades of experience. I have made mistakes. I have caught mistakes. I also had a similar error performed on me as a patient in an OR. Do I believe that the CRNA attempted to murder me? Nope.

PEH

Too many variables left unsaid about this to make a decision. Had this nurse just finished her 4th overnight 12 hour shift and gave this at 530am before her patient went to the O.R.? We’ve been there where it’s hard to even see straight, let alone try to differentiate between sound alike look alikes. Many law enforcement personnel say it’s worse driving extremely tired than after having a few drinks and yet hospitals are demanding nurses work extra shifts when they are burnt out, exhausted and holding lives in their hands. I agree with what has been said earlier and… Read more »

Karie Davis, MSN, RN, CNOR

What about her intelligent knowledge of the medication she was giving. I am by no means a recent graduate of nursing school (2004) but do know that pharmacology is a challenging subject and one that some nurses do not fully comprehend or investigate when uncertainty arises. What if she was pulling a medication for a CRNA or advanced provider and then due to instability of the patient was asked to give it? What if she did not fully understand the difference between the paralytic agent and the Versed. Not saying her lack of understanding would be in any means an… Read more »

Cynthia McKalip-Ballard

She is not guilty. If she is guilty, then EVERYONE is guilty. Nurses override muddled systems all the time for many reasons. The case should be dismissed. This is a multilevel sentinel event with much more to learn aside the fives rights.

VF

Why was a paralytic medication even available in a non-ICU? There is no reason for this medication to be stocked in a Pyxis machine outside of ICU. The hospital also failed the nurse by making this available. This does not discount her responsibility to check the medication she pulled, but it begs the question why was it available?

CTaylor

Sad all the way around. Intent is one of the key factors to be considered here.
“He without sin ( or near misses) cast the first stone”.

Radone

I agree, in order to be safe she should not have overridden the system. Checking med order and the medicine withdrawn would have been another safety check also verification with another nurse. Sorry that this has happened but mostly sorry the resulted in a death and the loss of a loved one for her family.

Stephanie Frankson

This should not have been prosecuted; as a legal matter, it belongs in a civil courtroom if the family were to choose that. In a civil case the nurse, along with the institution, would correctly be named as defendants. As is, this sets a dangerous precedent. If the nurse is prosecuted, so should everyone who had their hand in creating a policy which allowed this to happen. For starters, why was it okay to administer versed (also used for sedation) on an unmonitored patient? And, if the prosecutor defends his decision based on an override of an important safety mechanism,… Read more »

KC

I kept getting laid off from my first career so I returned to school to become a nurse – they always seem to need nurses, right? – wish I would have selected another career. Now I know why there’s always so many vacancies. I worked as a patient care assistant for 2 years while I pursued my associate degree in nursing. After I graduated and passed my boards I worked on a medical surgical unit for 7 months. Two years and seven months was enough inpatient care for me! Staffing is always terrible. We always had call offs because work… Read more »

D.L. Pickrel, RN, BS, RNAC-CTl

I would not call it an honest mistake. Their are safety overrides that should have set off warning bells to this nurse. Sound alike and look alike mistakes happen all to frequently. The labeling system of drugs needs to be standardized and contain both Brand and Generic names, or include the main action of the drug. It is less likely she would have given it if it said: Vecuronium – Paralytic Agent. With the acuity of care in many hospitals, and the speed at which they want you to perform; I can see this happening. Medication administration basics need to… Read more »

Sheila Parker

Murder nurse overriding a safety device.

Sheila Parker RN,MSN

David White, RN BS

I agree with Lawrence’s comment above. The nurse overrode the established safety mechanism and gave the wrong drug. Even though the Pyxis is supposed to help prevent medication errors, we all need to go back to the 5R’s we were taught in school. We are tied to tightly to computers.

Linda Caron, RN-C

I agree… This is Nursing 101. Obviously she didn’t check the med after removing it from the Pyxis or prior to administering it. The fact that the Pyxis did not release the med & she had to override it should have sparked a thought. I don’t care how busy you are (we’ve all been subject to understaffing & crazy nurse to patient ratios) BUT those are the times to check & double check.
So sad but agree with Lawrence, manslaughter.

E. German RN California

I do believe that this nurse made a fatal error. She should not have overrid the medication system and she should have at least verified the drug with another nurse and used the five Rs. But no one is blaming the hospital either for allowing her to do that. How was she allowed to override this deadly drug? I feel bad for her. Nurses take the brunt of the responsibility in healthcare. I believe that doctors make fatal errors just as often, if not more. They may not always kill the patients immediately, but eventually they die a slow dead… Read more »

Shelley

I wonder what the other mitigating circumstances were during her shift. Was she overriding because the patient was needing this procedure quickly and for what purpose? Was it a time sensitive one? What was staffing like? What was her patient load? How many shifts and hours had she worked prior to this one? I am by no means condoning this extremely unfortunate, tragic, and fatal act, but to rule blindly without considering what else was going on during that moment is not serving this nurse justice. Additionally, it’s easy for those who sit in ivory towers of administration who haven’t… Read more »

Johnson

This is ridiculous. Medicine is a PRACTICE and we are only human. Nurses are caring and compassionate. I am sure that this nurse did not wake up that morning and say ,”I think I will kill my patient today.” Prayers go out to this nurse!

Elizabeth Scarinzi

This sounds like it is ALOT more than an error. Vecuronium is NEVER kept near Versed.. Vecuronium is used to paralyze a patient including their respiratory muscles and is only used in order to gain control.over a persons airway in emergency or in an operative situation. This is most certainly medical negligence. I dont know about criminal as I dont know the nurses intent but something sounds very off.. Very concerning situation.

D Cantwell

I struggle with this one as the 5 R’s were somehow not followed here. However, I believe the greater blame falls upon the system: Why is Vecuronium in a Pyxis system on a (general) floor? Why was an over ride allowed on either medication; 1 a controlled substance, the other a general anesthetic. We used to utilize anesthetic agents in the ED (Seattle, WA), nurse administering, for THA dislocations. However, once the BON got wind of that, it was quickly stopped. BON decided this was NOT covered under a nurse’s license (of course different states allow for different things). Administration… Read more »

Pamela Luttrell

I know with OR and ER that the patient safety identifiers sometimes go by the wayside because of emergent situations especially when dealing with only one patient at a time.
I do not know the circumstances in this case. However, I do believe this will cause nurses to not report mistakes. Nurses are not robots. Human error will always come into play no matter what line of work you are in. Nurses save more lives than accidents take!

J Canavan, RN

The medication error was compounded by the nurse overriding the safety mechanism in the Pixis. But we’re there other circumstances in play such as, 1) Was this her area or had she been floated to help a staffing shortage, 2) Was the nurse familiar with the drug she was giving, 3) Was it reported in a timely manner?

Homicide….no. Negligent manslaughter….yes.

old school nurse since 1986

There are more concerns for that hospital than just this nurse. Neither drug choice was appropriate for that testing. And why was either of those drugs on a non-ICU or surgery unit? Those are such dangerous drugs that even 10 years ago they were not to be out of the ICU or surgical areas for everyone’s safety. Sometimes for convenience we forget the basics. My thoughts are that when we put such medications without restricting who has access and has the knowledge to use safely then we endanger ourselves and the public we serve.

Jose

Medical error is frequently in stressing environment where the nurses live on the daily basis, medications that look a like or sound a like, complicate the situation. If we add the fatigue, the time and more, the human factor, it’s something to take in consideration. We as a nurses, put in jeopardy not only our physical health but also psychological. Criminalizing the medical errors, I think deserve more study and research.

Lawrence Nelson

An honest mistake is pulling the wrong med out of the Pyxis (or whatever storage system is used); this instance was aggravated by (according to the article) the nurse overriding a safety device. There are so many tools to use (from the ‘five Rs’ on up to built in ‘nurse nannies) that could have prevented this, but it seems the nurse took a short cut and killed a patient. Murder? no. Manslaughter? Probably.

L.A. Nelson MS RN NHDP-BC
New Mexico