Criminal conviction for a medication error

[DrJenner]

Not sure if any of you have been following the RaDonda Vaught case. Basically, there is a nurse who was recently convicted in a criminal court for an accidental medication error that may have resulted/contributed to a patient's death. She had already been fired from her job and lost her license to be a nurse; which was appropriate given the egregious error that occurred.

This sets a terrible precedent. Nurses everywhere are already burned out and exhausted due to increased demands and less staff to do the job. It has always been in the culture of medicine to speak up when an error occurs and self report. RaDonda did this, and Vanderbilt Medical Center threw her under the bus. When errors are reported, we do root cause analysis to determine why the error occurred and take steps to fix the issue so it doesn't happen again. No one will want to report errors; leading to more errors and more mistakes being made.

The prosecution could not even prove that the med error lead to this patient's death. RaDonda administered what equated to 1mg of vecuronium instead of 1 mg of versed. Vecuronium is a paralytic, and in order to sufficiently paralyze someone to insert an endotracheal tube, you would need 10 mg for someone who is 100 lbs. 1mg would paralyze a 10 lb person. There are a lot of holes in this story, and something stinks to high heaven. The expert witness had not practiced in 20 years and really wasn't an authority to speak on the matter. I am hoping somehow the jury's decision can be reversed as this is already having far reaching consequences. Nurses are refusing to take verbal orders. Last week we were in a code situation and all the docs did everything as the nurses didn't want to push meds. Patient care is already suffering, and this is going to make things 10 to 100x worse.

https://istandwithradonda.com/ <---link to DA discovery

https://www.npr.org/sections/health...and-quitting-after-the-radonda-vaught-verdict

 

[Bacpacker]

I have been seeing some reports about this case. Never heard what the mix up was, and NO word of the dosage needed to work. With that knowledge, it sure don't sound right.

 

[Haertig]

Wouldn't criminal prosecution require the nurse to have broken some law? I wonder what that law was? Certainly, mistakes can lead to civil proceedings. But I was not aware of a law the criminalizes mistakes. What was she charged with? Was there supposedly malice involved, and not a mistake?

 

[DrJenner]

She faces 3 to 6 years in prison for neglect and 1 to 2 years for negligent homicide as a defendant with no prior convictions, according to sentencing guidelines provided by the Nashville district attorney's office.

She was acquitted of reckless homicide. Criminally negligent homicide was a lesser charge included under reckless homicide.

I'm not sure how they would prove malice. She was very forthcoming with her mistake and admitted it. I agree with her termination and loss of licensure, this was a pretty bad mistake. The vial very clearly states on the top ---warning paralyzing agent. She was distracted and didn't pay attention. There were no barcode scanners in the radiology area where she was giving the med and that will flag if you are scanning the wrong med (hence why the barcode scanners have been implemented everywhere). There were catastrophic system failures on the part of Vanderbilt, and I believe they settled with the family, but even the family stated they didn't want her to be criminally charged.

 

[billyjack]

I was mis-prescribed a medication about six weeks ago.

One of my wisdom teeth broke off. I went to the dentist and he wanted me to start taking an antibiotic for about three days before he extracted it until three days after.

So he gave me a prescription for the antibiotic and also for a pain medication for pain. His staff screwed up. I got the antibiotic but instead of the pain medication, I got some kind of anti-fungal mouthwash! I wondered about that but figured they knew what they were doing.

After he pulled the tooth and said to finish up the antibiotics on schedule, I asked him about the mouthwash. That really puzzled him. I kind of remember the name of it and told him. He looked at me and said something like "That's for thrush. You don't have thrush." and that it wouldn't hurt me to have used it. So he prescribed the hydrocodone that should have been prescribed the previous visit.

Fortunately, I never felt any pain, even while he pulled it and never needed any kind of pain medication at all. Well, a little pain before he pulled it -- the sharp edge at the break kept digging into my cheek.

I would have refused the hydrocodone since studies show that acetaminophen and ibuprofen taken together in the right dosages work better than hydrocodone for such pain, but I'm allergic to ibuprofen. So I got the hydrocodone and put it in a dresser drawer without even taking it out of the package. It's still there since I didn't need it.

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I also had an issue on another prescription a few years ago. I have to take levothyroxine every day. When I went into the doctors office that I went to then, they ordered the blood test which I then went over to the hospital and got -- when I go to the doctor to schedule a blood test, I make sure I haven't had anything in the previous 12 hours when I go to the doctor so I don't have to make another trip. After they received the results of the blood test, hey were supposed to call in the prescription to the pharmacy but never did in spite of numerous calls.

I was starting the paperwork to file a complaint with the state medical board when they called me. It turned out that she wrote down "continue as before" -- in other words, same dosage as before -- but the medical assistant who was supposed to call it in interpreted that to mean that I didn't need it any more!

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I also had a medical test done in a hospital in which the nurse doing the test didn't have the foggiest idea how to do it correctly. It was the ankle-brachial index (ABI) in which they take the blood pressure on each arm and each ankle and compute an index from them. Simple test, right? You're supposed to be lying on the examination table for the test but she absolutely insisted that she only does it with you sitting in a chair, thus affecting the results. Her exact words were, "Well this is the way that I do it." Also, there are two blood pressures to get on each ankle but she only got one.

When talking to the physician's assistant, he said that I should go to the cardiologist. I exploded at him about that. I told him that if it was based on that bogus ABI test, it was a complete waste of an entire day to go to the nearest cardiologist (200+ mile round trip).

I think that the doctors there went over to the hospital and gave a lesson on how to do the test properly. I mentioned the bogus test to one woman who replied that she wondered why they had her lie down on the examination table for the test when the previous times were all sitting in a chair.

For what it's worth, when I got home, I got out my sphygmomanometer and did the test on myself lying in a bed. Sure enough, the results were within the acceptable range.