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.
Indeed a useful post about medical mistakes, It’s best to learn from other’s mistakes than to feel the urge to commit one by oneself & then think of learning. I think we’ve all made some of these mistakes to some degree or another.
Coverup seems to be more common than I realized. I was orienting an experienced nurse, who was new to our facility, to our medication system & charting when another nurse near us said, “Watch out for her. She doesn’t know how to cover up her Med errors. She actually reports herself if she makes one!” Of course I was upset, but before I had a chance to respond, the nurse I was orienting said, “Thanks for the warning. I’d rather work with her than someone who covers up errors. Sometimes we forget the patients lives are in our hands.”
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 care areas when there was easier access- we still DID NOT have such easy access (pixys system or not!) to these meds.
And- there should have been further safeguards, such as:
– The need for at least 2 nurses to do any type of override to obtain either of these meds
– A lock out with an attempt to obtain these potentially dangerous meds.
-A pharmacy or supervisor approval for access to these meds.
It appears this was not an emergent situation. So why was versed being ordered/used? This is sedation. It requires constant monitoring of the patient in at least a post anesthesia setting. It is not an appropriate setting for any type of diagnostic testing.
Where was the ordering physician in this scenario?
Why isn’t anyone holding the physician accountable?
Also, prior to having any type of access to vecuronium, there should be more safeguards such as having emergency equipment and assistant in place- intubation equipment/ventilator, respiratory personnel, physician, anesthesiologists, CRNA’s, oxygen, etc…
This is very scary- it means any nurse could have access- very irresponsible on the hospital, pixys manufactures and pharmacy parts too.
I’m sorry, the “BLAME GAME” here is ridiculous! Too many times the hospitals and their lawyers are providing “DAMAGE CONTROL” instead of taking responsibility for THEIR ACTIONS or in this case- INACTIONS!!! This really makes me furious.
When something goes wrong- the nurse gets blamed!!!
Of course I am NOT saying the nurse was not negligent in administering the wrong med. Especially since the vec needed to be reconstituted.
However, there should be no reason the nurse should have been put in this situation in the first place.
Unfortunate as it is- it is only when grave mistakes like this happen- that better policies and safeguards are put into place.
But for Goddsake- prosecuting a NURSE for this will NOT help at ALL!
Yes, there is culpability on everyone’s part! And if you’re going to prosecute the nurse, you’d better be prosecuting the hospital administration, pharmacy administration and pixys manufacturer, ordering physicians, and I’m sure a few others.
There should be accountability for the entire system breakdown. Not ONE NURSE!
To set a precedent for future events like this to result in nurse prosecution is asking for trouble. I myself would not be willing to be a nurse anymore.
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.
This is so sad but true, It makes me angry, I often wonder why Nurses behave in this manner towards each other, as if the job itself is not stressful enough. We need to break this pattern so the future generation of nurses would be different.
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.
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 RN, I still remember the 2 weeks of training and then being floated one month later. Some RNs hire into float pool with no experience.
I will not commit further d/t the chance of being fired for these types of comments.
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 look up how to reconstitute it? Truly, without being a CRNA or Anesthesiologist, that med should not be available. But, I just cannot see an intentional murder on her part. That isn’t fair to put on any medical personnel without lots and lots of proof. It may be negligent but it isn’t murder. I am sure she is punishing herself much more than the justice system could ever do.
My thoughts exactly! The medications may have started with the same first 2 letters but still you have to look at the bottle/vial. In 21 years as a nurse, I have been in some very hairy situations but during the time it takes to prepare the medication for administration, you can certainly glance at the medication package during that time frame. As mentioned in the previous comment, I too have never given Versed for a procedure of this nature. I currently work as a Perianesthesia Nurse and whenever we do administer Versed for a procedure, the patient’s vital signs are assessed at least every 5 minutes and the staff are also at the bedside. I just don’t understand how everything could have happened the way that it did in this particular case.
I agree. I’ve been a nurse for 36 years and during my early years there were no “safeguards “ against med mistakes. You double checked with another nurse. Why on earth was versed available for that purpose anyway? She was probably overwhelmed with patients and overworked. I don’t think she should be treated as a murdering criminal.
I don’t care how overworked or overwhelmed she was. She gave a medication she was not familiar with. All nurses knows the rules of medication administration and she ignored at major one. It does not matter that she did not intend to cause harm or had no criminal intent. It does not matter that a machine dispensed a medication based on what she input. What matters is that she had a duty to the patient, she caused harm by failure to adhere to recognized standards and the harm was a direct result of her negligence. The classic definition of malpractice.
She did not read the bottle, she overrode the pyxis and didnt verify by looking at medication bottle. She admitted this in the CMS report. She did not look at bottle when she pulled the medication into syringe nor before she gave it. NEGLECT. I have read the report and she made alot of mistakes. Like typing in VE and clicking on first med in the list. GROSS NEGLIGENCE ON HER PART. Read the report
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!!
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 are diff kinds of overrides. One is an order is given stat- someone is putting in the order and someone is pulling the med at the same time. The med won’t be profiled under the patient yet so have to go to the override section. Only certain meds are in the override section depending upon the unit. Maybe the scanning area was next to OR and were sharing a Pyxis. The article didn’t show all the system logistics and what system failures occurred that also were culpable in the case.
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.
Sheila, I worked with you, I miss you and I wish I knew how to find you!!
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 & if that harms someone, then we are individually responsible for that. The healthcare system did their part by having the checks & balance system in place, so why override it? Sorry, simply no excuse.
I do find it hard to determine what the punishment should be, but what would we do if a pilot decided not to do his preflight checks & simply flew a plane full of trusting people that had a problem he didn’t know about b/c he didn’t follow proper protocol & he killed a plane full of people?
Let’s think beyond our emotions & excuses & simply consider our responsibilities as healthcare providers.
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
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.
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 hopefully they find out intent before criminally prosecuting because it will be a slippery slope and the nursing shortage will get even worse because of this.
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 escape in this situation but in a “Just Culture” we look at the system surrounding the error and do not immediately point fingers at the one who caused the error. There had to be other circumstances surrounding this error? To prosecute this nurse for a medication error of this magnitude will set the precedence for less reporting in facilities due to the criminalization of nursing errors. We have all made med errors, maybe not to this extreme, but to maintain a culture where we report this cannot be the persecution we face when we do report. Just my thoughts….
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.
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?
That’s right! It shouldn’t be stocked in a med machine outside of the OR even.
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”.
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.
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, then why is the hospital not being prosecuted for not having a scanning device (also an important safety mechanism) available at that time?
All of this begs the question, why, when multiple investigations found the institution also failed, yet the nurse alone is being held accountable? In fact, these findings have led to nationwide changes thus indirectly supporting the premise that she alone is not responsible.
This is a terrible travesty of justice!
I agree Stephanie! Probably because they figure the nurse has nothing to lose vs a major hospital . Seems like there’s no support for our hardworking nurses anymore. Large nursing graduating classes annually where I live. I’ve heard upper management say nurses are “a dime a dozen”. Shameful I think.
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 is so crazy. People are burnt out and leaving bedside nursing after a few short years! What a waste of college funds! Don’t even get me started on demanding and rude patients!
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 be easier, not more complicated by 15 letter generic names that are very difficult to remember. Come on big pharma…get over it, label things with human safety in mind.
Murder nurse overriding a safety device.
Sheila Parker RN,MSN
I am not a lawyer (nor did I stay in a Holiday Inn last night), but the definitions for murder, in most states, require a demonstrable intent. Manslaughter, on the other hand, only requires proving reckless behavior or reckless indifference (again, look at your state’s laws).
Consider this analogy – a person driving a car at a political rally intentionally rams it into a crowd of spectators (sound familiar?) and causes a fatality; they are charged with murder because the act demonstrated intent. A person who is DUI has a collision and kills the other driver and / or passengers. That would be either vehicular homicide or manslaughter, depending on where it occurred.
Regardless, the nurse has this burden to carry the rest of her life – all the more reason to go back to basics and use those ‘5 Rs’!
L.A. Nelson MS RN NHDP-BC
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.
Thank you. I am actually surprised that people are reading into this story and putting a lot of “what ifs”. What if a CRNA asked her to obtain the Vecuronium instead of Versed? What if it’s the hospital’s fault that this override system was on the Pyxis, etc. etc. We don’t know all what was involved. It was reported that she was supposed to give Versed. Instead, she overrode the system and grabbed Vecuronium. Although the first two letters in the medications start with “Ve”, standard medication administration is that you first, look at what you are typing in the Pyxis. And then if you didn’t do that, look at the medication name that you are grabbing from the Pyxis. And then, if you didn’t do that, then you look at the medication label before you administer it to the patient. I am sorry that this happened to her, but unfortunately her med error had some serious consequences and resulted in a patient’s death. And, if you don’t know what med you are giving, as a registered nurse, you should look it up to have a gist of what it is before you give it. That is the responsibility that we have as registered nurses. We took an oath. We have a license. And we have that responsibility.
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.
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 from their mistake. I really haven’t seen any consequences like this for any of them unless they obvious we’re doing it with intent. I think this punishment was too harsh. She made a mistake. And yes, she should loose her liscense, but mistake is the made word here. Big one. We are just human and us with more responsibility try our best not to make errors such as these. We double check and verify. But if you really think of it, her intentions were actually to bring her patient back to health. No kill them.
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 been on the floor to carry a patient load in a long time and for those attorneys to sit on their righteous thrones and pass judgment when they have no idea what it’s like to be a practicing bedside professional in today’s day and age. I’m sure she’s punished herself enough with the emotional turmoil and guilt she’s suffered. This wasn’t malicious, so to throw the book at her is, I believe, to only decrease numbers of professional nurses entering the profession and also decrease the number of reportings of medication errors.
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!
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.
She should have read the label 3 times…nursing 101.
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 of general anesthetic agents is best completed by an CRNA or anesthesiologist; therefore, should never be available to nursing staff especially in a drug delivery system (ie Pyxis).
D. Cantwell, BSN, PharmD, FNP grad 7/19
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!
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.
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.
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.
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
I agree. This will only cause less people to report errors because of the consequences like this. We don’t even know how in the world a nurse on a medsurg unit could get a hold of verconium or versed either. I’ve worked on medsurg units for 7 years and have never been authorized to give versed, especially to a patient to sedate them for an MRI. And what doctor ordered that? She laid in the MRI room unmonitored for 30mins. So there are a lot of factors in place. I feel sorry for this girl. She is taking the brunt of a major error that comes from many factors.
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