Do you ever feel that way?  Like you are shouting, and you don’t even hear your echo?  Well, welcome to me on this topic about medication errors and the Vanderbilt Nurse, RaDonda Vaught.

Ok, what the actual hell is going on here? Why is she being charged with murder?  The whole NPR article is here:

To refresh your memory:

She was trying to give the patient, Charlene Murphey, a dose of an anti-anxiety medication, midazolam (brand name Versed), before an imaging scan during a December 2017 hospital stay, the report states. Vaught instead gave Murphey vecuronium, a paralytic drug used during anesthesia that had the same first two letters, according to the report. Murphey died in an intensive care unit the following day.

She removed the medication from a secure dispenser known as PIXIS made by Cardinal Health (full disclosure I own stock in cardinal health, not controlling or anything, but hey). PIXIS allows you to enter patient info through a keyboard.  Once you have selected the patient, there is a medication profile that tells you which drugs the patient has been prescribed and are pharmacist verified.  As a rule, you only pull out one that is on that list. But, she is on a busy floor, and MRI has called for the second time annoyed that the patient isn’t prepped and on her way down.  In the meantime, she is also dealing with mundane requests that are being thrown at her like they are life and death.  She doesn’t see Versed (midazolam) yet and decides, “I need to get at least one monkey off my back” and overrides.  She types in Ver into the search line and on most floors Versed would be the first one, however on this floor for some reason, vecuronium is in the machine.  So PIXIS is stocked as needed, it is not some magic Star Trek replicator thingy that brings any med up. Why in the hell is an anesthesia medication in her floor’s PIXIS (this is on Vanderbilt and their Pharmacy) it is only used in the OR or in an ICU setting rarely) under very controlled circumstances? Midazolam is given for conscious sedation; it has the effect of amnesia and calming. She administers what she thinks is Versed and the patient dies because vecuronium is a paralytic that causes the patient not to be able to breathe without assistance. In the MRI she would not even have been able to call for help.  Scary and sad shit I agree.

She did fuck up though.  She should have verified the drug with the order before she gave it, not just counted on the PIXIS to dispense the correct medication (hell the pharmacy tech that fills those things could have put the drug in the wrong pocket).

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. The state health department investigation, which concluded in October 2018, did not revoke Vaught’s nursing license.

The CMS report emphasizes the hospital’s responsibility in the mistake. “The hospital failed to ensure all patients received care in a safe setting,” the report says. Vanderbilt University Medical Center officials would not comment on the case.

CMS is a tremendous player and does investigate these cases.  Read above, seems Vanderbilt is guilty here, also. So, are they throwing her under the bus with the help of the prosecutor?  Very likely.  The lawsuit on this one will be steep, and I am pretty sure like any hospital entity they are trying to make it look like they are a victim here, a typical corporate response known as covering your ass. Well maybe Vandy, I think we are familiar enough to call each other that, might take a look at how hard a nurse’s schedule is and how detrimental overworking a nurse is.  Maybe we need an overall reform that brings us back to when a hospital wasn’t like a 24/7 “wait on me hand and foot” environment. Yeah, I said it.  If you can ambulate safely, then get off your ass, come to the nurses’ station and get your own ice or water. Come and ask for your turkey sandwich, hell I say come and ask for pain meds, but I am told that is a little too much (although ambulating may improve your overall pain levels).  Look it may not be a total answer, but half a guess says she had at least one patient ringing the call bell wanting ice that was more than capable of coming to get it. Sorry, but as an advanced practice nurse, I find this disconcerting that patients aren’t encouraged to do more for themselves.  It promotes independence and enhances mobility, things they will need at home. Ok so

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

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.

DA spokesman Stephen Hayslip told NPR in an email that “the actions of this office will become more evident as the evidence is presented to the court.” He declined to comment further.

So, what sinister evidence do they have that makes this different? Unless it is a surprise twist where Vanderbilt gets hung out to dry (yeah no, a significant employer in town and it does have the Vanderbilt name on it we wouldn’t want to smear that) in this. Or Vanderbilt wants it not to be saddled on them (the more likely). Look the hospital you go to wants you to come to them and spend your insurance dollar. Hell, ever driven down the road and seen a billboard with ER wait times on them?  Exactly, they are fighting for your insurance dollar like a cheap ass carpet outlet.

Suen Ross, the ANA’s director of nursing practice and workplace environment, thinks that it’s unusual for health care providers to be charged with a crime after a medical mistake that didn’t involve malicious intent or intoxication. She calls Vaught’s case “unprecedented” because neither of these factors are cited in the CMS report.

Ross says it’s important for health care workers to feel free to report errors without fear of retribution. All health care mistakes — even small ones — should be analyzed to understand the underlying issues that caused them, Ross says.

A non-punitive approach encourages transparency, she says, and “that prevents future mistakes or errors from happening.”

This approach to preventing errors is well-accepted in the medical and nursing communities, which makes a criminal case like Vaught’s all the more surprising, says Kirstin Manges, a nurse and researcher at the University of Pennsylvania who studies patient safety.

“That could have happened to me, or it could have happened to my friend,” Manges says. “Nurses aren’t superheroes. We’re people.”

She’s wrong on one thing, Nurses are superheroes.  They do an impossible, emotional, and often traumatizing job every day with very little outside support, except their family. As a medical community, we owe it to ourselves to support each other because like here our employers and the local community tend to fuck us over at the first chance.

Now I am on a rage, as should you be.  Have a good day anyway and hug a colleague (with consent of course) and tell them how amazing they are.