When is a medical error a criminal act and what is your risk of being thrown under the bus if you make a mistake?
A nurse was recently convicted of a criminal act - negligent homicide - for a 2017 medical error at Vanderbilt University Medical Center in Nashville, TN.
This precedent setting case has sent shock waves through the nursing community. It will almost certainly result in hesitation to report medical errors in the future.
When you read the testimony it is clear that her employer's severely flawed systems of care are at least partially to blame for this tragedy.
It is important all physician and staff employees of healthcare delivery organizations dig a little deeper here to see the huge missing pieces in this verdict that place YOU AT RISK for a similar travesty of justice.
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In this blog post, let me show you some details of the case as reported by NPR and ask some very important questions that the verdict leaves open for interpretation.
As you read this post, I encourage you to think about your personal risk of a similar "bad outcome". Contemplate the following questions:
>> Where does my employer force me to work in an inefficient and error prone system that raises the probability of a mistake?
>> Would they throw me under the bus if I made a mistake within a flawed system of care, if their legal team could successfully deny their share of liability in court? (BTW, the answer to that question is certainly "YES" as proven here.)
THE TRAGEDY AND THE LEGAL OUTCOME:
In December of 2017, nurse RaDonda Vaught was prepping a patient for an MRI. She accidently administered vercuronium instead of Versed in a medical error that left the patient, 75-year-old Charlene Murphey brain dead as a result. Ms. Murphey died in 2017.
Nurse Vaught did not deny blame for the error:
"I know the reason this patient is no longer here is because of me. There won't ever be a day that goes by that I don't think about what I did."
Under normal circumstances, the Tennessee Board of Nursing would have revoked her license and almost certainly ended her nursing career. That will certainly happen, but in this case a new precedent is being set.
She was served criminal charges of reckless homicide and felony abuse of an impaired adult for the killing of Charlene Murphey.
On March 25th she was convicted of gross neglect of an impaired adult and negligent homicide after a three-day trial in Nashville, Tenn., that was closely watched by nurses across the USA. She faces three to six years in prison for neglect and one to two years for negligent homicide as a defendant with no prior convictions.
WAIT JUST A MINUTE. You have to see some of the evidence produced at trial to understand what happened that day.
WARNING ... this will only raise more questions as to who was at fault and specifically, what role did the Vanderbilt system of care play in this tragedy?
THE DETAILS OF THE CASE
as reported by this NPR article
Italics are mine.
"The case hinges on the nurse's use of an electronic medication cabinet, a computerized device that dispenses a range of drugs. According to documents filed in the case, Vaught initially tried to withdraw Versed from a cabinet by typing "VE" into its search function without realizing she should have been looking for its generic name, midazolam. When the cabinet did not produce Versed, Vaught triggered an override that unlocked a much larger swath of medications, then searched for "VE" again. This time, the cabinet offered vecuronium.
Vaught then overlooked or bypassed at least five warnings or pop-ups saying she was withdrawing a paralyzing medication, documents state. She also did not recognize that Versed is a liquid but vecuronium is a powder that must be mixed into liquid, documents state.
Finally, just before injecting the vecuronium, Vaught stuck a syringe into the vial, which would have required her to "look directly" at a bottle cap that read "Warning: Paralyzing Agent," the DA's documents state.
The DA's office points to this override as central to Vaught's reckless homicide charge. Vaught acknowledges she performed an override on the cabinet. But she and others say overrides are a normal operating procedure used daily at hospitals.
While testifying before the nursing board last year, foreshadowing her defense in the upcoming trial, Vaught said that at the time of Murphey's death, Vanderbilt was instructing nurses to use overrides to overcome cabinet delays and constant technical problems caused by an ongoing overhaul of the hospital's electronic health records system.
Murphey's care alone required at least 20 cabinet overrides in just three days, Vaught said.
"Overriding was something we did as part of our practice every day," Vaught said. "You couldn't get a bag of fluids for a patient without using an override function."
Overrides are common outside of Vanderbilt, too, according to experts following Vaught's case."
"During the trial, prosecutors painted Vaught as an irresponsible and uncaring nurse who ignored her training and abandoned her patient. Assistant District Attorney Chad Jackson likened Vaught to a drunk driver who killed a bystander but said the nurse was "worse" because it was as if she were "driving with [her] eyes closed."
Vaught's attorney, Peter Strianse, argued that his client made an honest mistake that did not constitute a crime and became a "scapegoat" for systemic problems related to medication cabinets at Vanderbilt University Medical Center in 2017.
My number one question is this:
Where is Vanderbilt in this case?
I am pretty sure you have some questions about the med delivery system here - as do nurses across the country.
- She made a mistake on one of 20 overrides she was instructed to perform by her managers.
- She reported her mistake.
- She is going to jail as an individual, just doing her job.
- Her employer is mysteriously absent from the court proceedings and presumably has been cleared of any liability here.
OH MY !
Surely there is liability in this situation shared by a number of additional parties who contributed to this work environment.
SO MANY QUESTIONS
- What about Vanderbilt's liability for systems of care that had to be overridden daily just to get the meds needed to treat patients? This must have created conditions similar to the know phenomenon of alarm fatigue in nurses.
- Surely it is obvious that constant overrides of this system increase the chance of errors and that the system is the problem?
- Surely it is obvious that the increased stress of the multiple overrides on the typical busy day in the hospital must have increased burnout in the nurses; a known cause of increased medical errors?
- Has Vanderbilt used this case to trigger a comprehensive review of medication ordering and delivery systems to eliminate the need for frequent overrides?
- What about the liability of the company that created the medication delivery technology, sold it to Vanderbilt and trained their staff in its use?
- What about Vanderbilt's HR/Quality oversight that allowed a nurse that, "could not bother to pay attention to what she was doing", to be hired and work within their systems?
- How does the financial ability to hire a top notch legal team compare between Vanderbilt University Medical Center and nurse Vaught?
- How hard is it to find a good lawyer in Nashville, TN who will go up against the Vanderbilt healthcare juggernaut - probably damaging their reputation significantly?
ARE YOU AT RISK TOO?
- Where are you being forced by your employer to use systems that are inefficient, stressful and provide increased opportunities for mistakes to happen?
- What would your employer do if you made a significant medical error that took the life of a patient?
- What are the odds that they would abandon you to a criminal charge if their back was against the wall?
PLEASE LEAVE A COMMENT
What are your thoughts/concerns/fears about the details of this tragedy and the precedent it sets for you as a healthcare provider?
SOURCE ARTICLES for this blog post
As a nurse faces prison for a deadly error, her colleagues worry: Could I be next?
Former nurse found guilty in accidental injection death of 75-year-old patient