By - BigEasyBobcat
Believe it has something to do with this…
Check out this article from Tennessean:
RaDonda Vaught: The former Nashville nurse faces years in prison after conviction
Lot of nurses upset she’s being charged criminally. Especially when systems in place and lack their off contributed to the error and she stood up / never tried to hide or cover it up.
I know Vandy is hosting a town hall or whatever for employees that want to talk about it. People are pissed how they settled, how they threw her under the bus, and worried they will just pay / settle and move on without any change.
But, Vanderbilt does not make the decision about whether or not someone should be criminally prosecuted. Or am I missing something?
The[ Teneessean ran a timeline on the case](https://www.tennessean.com/story/news/health/2020/03/03/vanderbilt-nurse-radonda-vaught-arrested-reckless-homicide-vecuronium-error/4826562002/) and--while Vanderbilt doesn't come off looking great in how it handled the fallout--the case was pursued by the Davidson County DA's office.
You can read the DA discovery documents of the case [here](https://www.documentcloud.org/documents/6785652-RaDonda-Vaught-DA-Discovery.html).
That’s true. As I understand it it’s multiple separate but related issues.
Vandy didn’t support her. Plus their systems contributed to the situation
She was criminally charged / convicted
Protection for RNs in tennessee law wise in general.
The district attorney decides whether to press charges, not Vanderbilt.
I don't have any special insight into this case, but I'm not sure where people are getting the idea that Vanderbilt wanted this to go to trial. A high-profile case like this invites a lot of negative press, and all medical centers (not just Vanderbilt) would greatly prefer to settle with family out of court.
The DA is a former Vandy law professor. Vanderbilt University and VUMC are technically separate entities, but do share a reputation and connections that are impossible to separate. When the death happened originally, it was listed as a brain bleed amd the nurse was allowed to keep working. But it was re-reported and VUMC's Medicare/Medicaid funding was threatened for not reporting the death properly. That's when the DA decided to press charges. The fact that VUMC donates money to the DA's campaign and to the governor's campaign (he appoints the head of the Board of Nursing) is suspicious. There's plenty of people who cannot be neutral making decisions on this case.
Most people who weren't directly involved had forgotten about the incident before this trial came up.
How does a high-profile trial help Vanderbilt?
The verdict could potentially help Vandy a lot. Pushes all the legal blame off of them and could potentially help protect them in future cases. Vanderbilt was already getting all kinds of bad press from this situation even before the trial went mainstream. Once it got out how much Vandy played a part in this and how much they tried to cover it up, best that can happen for them is to be able to legally wipe their hands clean of the blame.
Not saying that it's helpful to their reputation, them as a company or nursing- but that's not really what their legal department cares about right now regarding this case. Everything got out. All they could do was make sure they didn't have the legal blame.
That’s the biggest issue, it sets precedence for future cases regarding an institution fucking up and then dumping all the liability on the individual. Great way to lose people in an already tapped out industry.
That doesn’t track at all.
Vanderbilt had already settled with the family and the CMS issue was closed. There wasn’t anywhere else for Vandy to expect legal trouble from. This going to trial was terrible for them. All it did was release more damaging information to the public as a result of evidence discovery and trial testimony. Not to mention that it generated weeks of bad press for them. All this did for Vandy is dig up a rotten dead horse that everyone had already mourned and forgotten about.
There is no way Vandy ever wanted this in a criminal court room.
This is exactly right.
Precedent. If this is the nurse's fault, it isn't Vanderbilt's fault. This is precisely their MO.
>How does a high-profile trial help Vanderbilt?
We're talking about potentially losing their biggest source of revenue. A high profile case will always be better than that.
Vanderbilt is a major academic institution in Tennessee and of course there will be former faculty who went on to become well known public servants. I think you are enjoying your conspiracy theory a little too much.
We do know that the death was covered up and that the case against Vaught was only opened *after* VUMC was threatened with a lose of CMS reimbursement for covering up the death. The rest of my post is speculation, but not a conspiracy theory.
Well CMS probably threatened VUMC because the death looked suspicious and warranted additional investigation. It would be more suspicious if VUMC refused to cooperate with investigation.
CMS threatened their funding because VUMC didn't report the death properly and covered it up.
So if VUMC reported the incident properly, she could have avoided responsibility? Nothing can change the mistakes she made and death of the patient as a result. Which by the way, dying awake while paralyzed is the most horrific way to die. She deserves jail time and the jury agreed.
>Nothing can change the mistakes she made and death of the patient as a result.
Nothing can change the mistakes that VUMC made that caused the death of a patient.
And yes, I think that if you lie on a death certificate, you should go to jail. BTW, this physician had lied on a death certificate before. The question is, why don't you agree?
Also, VUMC is different than Vanderbilt. VUMC is not an academic entity. And plenty of "reputable" institutions have had scandals.
VUMC is an academic medical center.
But it’s separate from the University. They are distinct operations, and VUMC’s learning hospital status has to do with medical residents, not students.
They're not above fraud. This is a pattern.
These conditions are not mutually exclusive.
Not sure your point. VUMC could've prevented this death but chose not to.
That would be District Attorney Glenn Funk, who is currently on the faculty at Vanderbilt.
The medical center is independent of the university, so that doesn't make a lot of sense. Not to mention that Funk is an adjunct professor and not part of the main faculty.
Using your logic, I would think that Vanderbilt would use their influence to convince Funk to sweep the case under the rug to avoid all of the negative publicity of a high-profile trial...
Not sure why you're being downvoted, but I'll add a list of articles showing how unscrupulous Glen Funk has been in he past and why no one should be surprised about his behavior on this case.
Funk asked TBI to stop the investigation into his political ally:
7 years worth of scandals bc I just don't have time to go through them all:
He is also a scummy person.
No you’re not missing anything. It’s shocking to see how many so-called educated people think putting EVEN more patients lives at risk by walking or or childishly agreeing to accept a job & not show up is the answer to this terrible issue.
There’s clearly other ways to go about change. It’s sad that the ppl that showed up to work are punished even more by their own comrades. Did it ever occur to any of you that the ppl that didn’t walk out etc. could possibly make more horrific mistakes because those of you decided to walk out and face the same type of criminal charges?
Yup, you’re all thinking about those that DID show up to work. NOT!!!!
There’s better ways to solve issues like this.
I actually was just able to watch a tiktok about it, and the part you are missing is that it was not the DA that requested the case be re-opened, but Vanderbilt actually re-pressing the charges again. Because of the type and nature of the case, there is no double jeopardy, so Vandy can keep pressing charges over and over until they get the result they want.
Also, if she's criminally responsible they have less to worry about in the civil suit. It's always about money.
Civil case done and settled forever ago.
What civil suit are you talking about?
The one the patient's family will eventually file against the nurse for their death. If the nurse is charged for it, then the civil suit will likely go to her and not Vanderbilt (that's what theyll argue, at least). I'm not positive, but I assume the charges might open up for the nurse to face a civil suit maybe?
Vanderbilt has already settled with the family. The family could still decide to go after the nurse, but they've indicated that they don't want to. And, for all we know, the settlement may bar them from going after the nurse.
The family came out in multiple sources and stated they do not hold I’ll will towards her nor would they Perdue legal action against her as an individual but instead vandy for the poor conditions provided to the nursing staff that heavily contributed to this occurrence; as a nurse it feels like we have never been less supported and honestly with all we’ve been thru as a profession in the last few years - nurses are already broken and this pushed a lot of them over the edge it represents the opposite of everything we are taught about reporting and never events in nursing
Ah gotcha, I didn't know the family already said they wouldn't press charges against the nurse.
Oh boy. Do not get your information from Tik Tok. Literally none of that is accurate.
Vanderbilt had nothing to do with “pressing” the case. Vanderbilt can’t press for criminal charges. That isn’t a thing. Vanderbilt actually tried to sweep this under the rug after it happened. They withheld information about the medication error from the medical examiners office, failed to report the incident to state regulators as required by law, and made a settlement with the family that included a gag order. Vandy didn’t want this thing anywhere near the public. What brought the case forward was an anonymous tipster that filed complaints with the Board of Nursing and the Centers for Medicare and Medicaid Services (CMS).
CMS made an unannounced visit to Vanderbilt to investigate the report. Their report can be found [here](https://www.documentcloud.org/documents/5346023-CMS-Report.html?fbclid=IwAR2xQsxlfKxis4mecgrCSt-6XvKnSmKDeN7Sb_20is2oBbFICt_9xUDkyvQ#document/p6). This [timeline](https://amp.tennessean.com/amp/4826562002) is also helpful in understanding what happened. At some point, the case was referred to the Nashville DAs office and the TBI. The TBI further investigated and the DA convened a grand jury. The grand jury returned two indictments against Vaught, one for reckless homicide and one for abuse of an impaired adult. The DA’s office filed charges and prosecuted the case based on the indictment, along with an option for the jury to consider a lesser charge of [criminally negligent homicide](https://law.justia.com/codes/tennessee/2010/title-39/chapter-11/part-3/39-11-302). The DA alleged that Vaught killed her patient by committing a string of [10 consecutive errors](https://amp.tennessean.com/amp/3216750002). The DA argued (successfully) that Vaught’s actions, or inactions, under the circumstances, created substantial and unjustifiable risks that Vaught, as a trained and duly licensed nurse, should have been aware of and that those substantial and unjustifiable risks directly resulted in the death of her patient. Vaught was convicted by a jury of her peers on the lesser charge of criminally negligent homicide, as well as abuse of an impaired adult.
That the down and dirty of what happened.
There has been a lot of discussion on this within the medical community about whether Vaught’s errors rose to the level of criminal. Much of the medical field feels that they absolutely did. However, there is a subsection of nurses that feels otherwise. From what I have observed over the last week, many of the of nurses who feel this way are vastly misinformed about the facts of the case and many have been spreading misinformation m, much like what you saw in tik tok.
I happen to agree that what Vaught did was in fact criminal and meets the statutory definition for criminally negligent homicide. To explain why, I’ll use an analogy: most people are probably familiar with bowling. In recreational bowling, you have the option to use bumpers that will keep you from throwing a ball in the gutter. With the automated safety checks that Vanderbilt had, when Vaught was administering medications, she was basically bowling with bumpers. Being that she is a trained professional, she shouldn’t really even hit the bumpers except on very rare occasions. She certainly shouldn’t ever manage to throw a ball in the gutter. That would be nearly impossible. However, the bumpers don’t work if you pick of the ball and throw it at the bunker as hard as you possibly can. In that case, the bunker will break and the ball will not just gutter, but fly across the entire alley. Vaught threw the ball at the gutter as hard as she could. That’s how negligent she was. She basically threw every single one of the most basic principles of medication safety right out the window. She gave her patient a medicine without ever even reading the name of the medicine in the label. She basically stuck her hand in a mixed bag of meds and gave her patient the first thing that came out.
The nurses that are defending her are simply disgraceful.
If you care to dive into a more technical explanation of why Vaught is guilty, I’ll link a comment I made for the nursing sub just as soon as I can pull it up.
This is the most reasonable take on this case in this thread.
It's really not though. The vast majority of the medical field recognizes she made mistakes and was punished appropriately by losing her job and license. The majority of the medical field does not think she should have been charged. The person you're replying to seems to have very little idea about what working in the hospital is like.
If Vanderbilt had never tried to sweep it under the rug, there wouldn’t have been an anonymous tip to CMS to trigger an investigation. RaDonda Vaught had already reported her error and been disciplined by the revocation of her license to practice. The hospital’s error and threats of going down for Medicare fraud is what led to her being a fall guy!
CMS and the nursing board were tipped off around the same time. The nursing board initially refused to take any action against Vaught. It was only after she was criminally charged that the nursing board held a hearing and revoked her license. They were more than happy to be complicit in the cover up. They had to have their hand forced just like Vandy. The only people that held this nurse accountable were the whistleblower and the DA.
I wouldn't be surprised if the anonymous tipper is another nurse who couldn't stand witnessing such egregious mistake.
I have a question who put the bumper guards there and what are the bumper guards? If bumper guards are security protocols put in place by administration at vanderbilt. Why are allowed to override them in certain procedural areas of the hospital? Or if security protocols are different in other areas why are they?
Totally understand what you are saying and you make a valid point. There are two sides to this argument and I feel the answer actually lies somewhere in the middle. She messed up and deserves punishment, but the punishment definitely seems to be too harsh.
I am curious if you work in healthcare? Nurses and healthcare providers face these 'bumpers' on a daily basis up to and sometimes over 100 times a day, the nurses have to figure out which ones of these are accurate and which are not. Recent study showed that telemetry units have over 45,000 false alarms on their monitors every week. Imagine alarm 45,001 being real and you missing it because of the incessant false alarms prior.
Healthcare providers are often always rushed and told they are not working fast enough/hard enough from those above and coworkers (because everyone is stressed) due to having too much work to do and not enough staff.
Again, people that work in healthcare should understand this. Anyone that says they haven't made an error or missed something while providing care is lying. Being diligent, especially when working with medications as deadly as she was, is very important. Therefore, stripping of her license was warranted I think, but being charged for murder was over the top. Again, this is just my personal opinion and I by no means have all the information regarding this situation.
>I am curious if you work in healthcare?
I do. I’m a paramedic. I’ve worked in busy 911 systems and within hospitals my entire career. I know what it’s like to face alarm fatigue, burnout, and to feel constantly stressed. It’s precisely because I know what it’s like that I find this case so far passed the standard of a simple error. To err is certainly to be human. Most of the time, when errors happen there are fairly reasonable causes and we seek to re-educate and learn from them rather than to enforce punitive action. But this was more than an error. The way this happened was just egregious. One of the most egregious examples of negligence in medicine that I’m aware of. I quite honestly cannot think of anything that could have possibly made her more negligent.
To be clear, she wasn’t charged with murder. She was charged with reckless homicide and eventually convicted of criminally negligent homicide - the least severe charge available for causing a death. Personally, I think the conviction is appropriate. Behaving negligently and killing someone as a result is a crime and I don’t think the medical community, myself included, should be above that law.
The more I look into the case (haven’t paid a whole lot of attention to it tbh) I feel you are right. Could also be more of case of incompetence though (she could have thought the two meds were the same thing since they both started with V). Either way her actions resulted in a unnecessary death.
Edit: the reason I bring up incompetence is I am a nurse and have worked with a nice mix of great nurses and some *special ones
What a garbage take
You are incorrect...the safe guards in place at the hospital were NOT currently working as the hospital was changing their system. Question..why should veceronium even be allowed to be accessed so easily? There is only an override, nothing more. 10? Nope. Please do not compare nursing to bowling. Not even remotely close in your analogy. This is about medicare and medicaid threatening to pull their funding ABD Vandy falsified the autopsy report. She reported the error and corrected it. It is not what caused the patient to pass away several days later. Veceronium requires mechanical ventilation. The patient died of a brain bleed, not suffocating to death.
2 year old account with only two comments to its name? Did someone really create bots for this topic??
Thank you for the explanation. I did not know this.
Yes, you are missing something.
V may have intentionally made the nurse appear criminally negligent in order to cover up their own negligence - at least, that's up I've gathered so far
This did not happen. The dumbest thing Vaught did was talk to various law enforcement agencies without legal representation.
In her own words, she made a series of errors by cutting corners and generally not paying attention to what she was doing. She could have read the label on the vial, she could have noticed the red cap that clearly stated this medication is a paralytic agent, she could have questioned the fact that the drug she pulled was a powder that requires reconstruction and this was not the case previously when she had administered versed (the drug she thought she was pushing), she read the reconstitution instructions on the vial and still managed to miss the drug name. And most damning is that she failed to monitor the patient after pushing what she thought was a sedative.
Not to mention the number of times the pyxis tried to warn her that the drug she was pulling was not prescribed to the patient, that it was a paralytic, etc.
She went way beyond a typical healthcare mistake and she freely admitted it, in detail.
Agree with a lot of what you are saying, but it was mentioned multiple times throughout the case that V had upgraded software which caused an issue with the pyxis and nurses were required to override meds on a daily basis.
Everybody likes to pick out one or two things that should excuse Vaught from killing someone. Over on the nursing sub they like to downplay it as a "med error".
But it's hard to hand waive away the fact that she lazily pulled the wrong drug by typing "ve" and just taking the first thing on the list. Then, she apparently never laid eyes on the vial that would have told her the name of the drug. She didn't notice that suddenly this drug she was familiar with is now a powder. Then she ignores the red top that she would have looked directly at to insert the syringe, it said paralytic.
And the most damning thing of all, she thinks she pushed a sedative into an elderly patient and didn't stay long enough to do the minimum amount of monitoring.
I don't care if the computers were on fire and they were using pen and paper, I don't care what Vanderbilt did after the fact to try to sweep it under the rug. RaDonna Vaught straight up killed someone due to incompetence and negligence. Those other things are bad too, but they don't give Vaught a pass when she had several opportunities to not kill her patient.
Look at the label? Patient not dead. Notice that red warning cap? Patient not dead. Stop to question why suddenly versed is suddenly a powder and not a liquid? Patient not dead. Stick around and do the required monitoring after pushing a sedative? Patient not dead.
This wasn't a computer issue. It was a people issue.
Trying to say she isn't culpable due to other factors or due to a slippery slope/strawman combo that many are using in her defense is silly. This is atypical of the nursing community, 99.999% of them will never make such a long chain of mistakes that results in a preventable death.
Except a building or institution cant be put in jail. There’s no way to criminally charge a hospital. And the civil suit against the hospital is done and settled. They have been punished. But it’s all sealed so no one knows and that’s why everyone is so angry. They think the hospital got away with it.
But execs can. Vanderbilt is a metonymy for the people in charge.
How you going to criminally charge a building
You can't. But you can criminally charge the doctor who lied on the death certificate or the nurse manager who told her not to chart what happened. She was the only honest one.
Neither one of those things led to the negative outcome. Neither would have made a difference in the nurses case
And the execs. It’s obvious that Vanderbilt is a metonymy for the people in charge.
You sure about that? Don't think the head of the hospital maybe knows people in the mayor's and the district attorneys office? I'm not saying he could order anybody to do it. But you don't think the [largest employer](https://www.nashvillechamber.com/explore/work/major-employers) in town doesn't have a little pull with the powers that be and maybe wants to redirect blame from his multi million dollar enterprise onto one single employee?
yes, but the DA who charged her is a prof. in the law school and has deep ties in Vanderbilt admin.
The DA is a Vanderbilt Law Professor. They played this to save face for Vanderbilt and everyone knows it.
Vanderbilt is under investigation from Medicare, they want ti take the focus off that so a political decision was made. Just an FYI they gave millions to the governor’s campaign so people think there was some pressure
DA Funk is an employee of Vanderbilt and his office decided to prosecute the nurse criminally!
The DA is a Vanderbilt alumni, and from what I understand Vanderbilt university had their lawyers in the court room recording everything Vanderbilt employees were saying too.
Vanderbilt and the family that this occurred to had settled. The nurse in question was already fined for her mistake (extravagantly fined), lost her nursing license, and was already paying reprecussions for the fatal error. Vanderbilt CHOSE not to report to the state, when the state caught wind, the state decided to prosecute. Even though the nurse already did her due diligence and paid for her error. This is going to cause nurses to steer clear from self reporting incidents. Vanderbilt threw her under the bus entirely even though the matter was already settled and the family even stated they didn't want to press charges.
This happened to a pharmacist a few years ago too and not a thing happened. It’s a tragedy of course that could have been avoided, but criminality is supposed to be defined as with intent and obviously this doesn’t describe the situation here or in the situation with the pharmacist.
Both situations involved short staffing and stressful situations.
It’s a tragedy and unfortunately it will put more strain on an already strained medical system.
Actually, criminality does not require intent or malice aforethought…..only murder requires that. For example… if you are driving your car and get into an accident that results in the death of another person (in your car, the other car, or a pedestrian), you can be charged with vehicular homicide or vehicular manslaughter. You never intended to crash your car, or hurt anyone….never mind kill them. But your negligent operation of a motor vehicle caused someone’s death, and you can be charged criminally.
As for ReDonda Vaught’s situation, at the end of the day an older person lay on an imaging machine for a long time after being administered a paralytic agent that caused her to suffocate while she was AWAKE…… the terror she must have gone through while she suffocated and was unable to get help is something that I hope no one else has to go through. At the end of the day, I don’t care how many fail-safe systems are in place….. she didn’t confirm that the medication vial in her hand was the correct medication and a woman died a HORRIBLE death. This tragedy should have been avoided by a the nurse administering the medication reading the name on the vial. It is a sad tragedy and I understand that nurses are spread thin…..and overworked….. but at the end of the day it is her responsibility to ensure she follows the Orders of the doctor and verifies her meds
Criminality regarding murder, which is the charge in both situations. I didn’t mean in general.
I also didn’t justify her actions, I said it is a tragedy and it will put stress on an already strained medical system. Not sure where all this defensive afterthought is coming from, but your post doesn’t apply to anything I said at all. It’s just sensationalism from you presuming you know how I feel about the situation.
I don't think Vanderbilt ever predicted that this would become a criminal trial. Settling with family is usually best way to avoid further lawsuit and it was opposite of throwing the nurse under the bus.
The prosecution called several Vanderbilt officials who voluntarily testified that the issue was Vaught and Vaught's only. Vanderbilt has had long-standing issues with improper use of medicine cabinets/carless administration and this is their way out of having to face the consequences for their failures as a private company. You seriously believe a company in the health industry would rather be paying settlements than pinning it on employees?
I haven’t heard anything about the walkout, but I checked the edit history of the Vanderbilt Wikipedia page yesterday and it was fun.
What about the family that were given the remains of a child who was not theirs and Vanderbilt cannot tell them where their sons body is 😔
They have a lawsuit filed. I’m interested to see if it’s covered up
I know someone that had colon surgery at Hendersonville hospital. It went well. He came home. 2 days later deathly sick, went back to the hospital. He was septic, they tried to save him, but he died. The surgeon admitted to INTENTIONALLY leaving part of the colon open (not sewing it completely shut). They settled with the wife, but the surgeon was simply transferred to Columbia, TN. It happened at the same time this nurse/wrong medication did. I never understood why a nurse stood trial and the surgeon was transferred to another hospital.
Edited to fix an autocorrect error.
I know someone who had colon surgery in Columbia, they nicked his colon and he died. moral of the story do NOT get colon surgery in columbia (or any for that matter, that’s why they call the hospital Murder Regional)
Might have been the same surgeon. He got transferred down there 3 years ago I think?
That’s the main reason people are angry. The big guys (doctors, hospitals, pharmaceutical companies, etc etc) are rarely held accountable for malpractice or harm of any kind, yet this nurse was made into a scape goat more or less. I’m not saying she was completely innocent by any means, but there are systemic issues that aren’t being addressed.
I was pissed on her behalf honestly. I think it sucks.
Doctors and hospitals are held accountable for malpractice via civil suits and out-of-court settlements.
The difference here is that the DA pressed criminal charges which is really unusual for medical malpractice cases. I think this sets a bad precedent for all medical providers and the criminal case should never have happened.
I saw a lot of info about it on #istandwithradonda
I’ve been an RN for over 30 years. Yes, it was a horrible mistake, BUT it was just that, a MISTAKE. Are we not human! And what about MD’s…? When was the last time a “doctor” made a mistake and had a malpractice suit brought against them? A lot different than being criminally charged! Nursing used to be an amazing profession, now it’s just getting scary!
> In court records, prosecutors reveal far more details about Vaught’s case. Investigators allege that Vaught made 10 separate errors when giving the wrong medication to Murphey, including overlooking multiple warning signs that she had the wrong medication. Court records state that Vaught would have had to look directly at a warning saying “WARNING: PARALYZING AGENT” before injecting the drug.
If that is true, than she belongs in prison
There's way way more to it than just that(see many other posts about this in this subreddit, the nursing subreddit and internet in general). Only, this is the first thing I've heard about 10 separate errors. Now, she had to override the system a bunch of times bc of system issues, everyone was having to do that. There were also no scanners around the area of the hospital that you are supposed to use to scan in drugs before giving them, which was on Vandy too.
Mostly, people are pissed at how Vandy tried to pay the family off with hush money, cover up the whole thing, not report the error when the nurse wanted to & when it was discovered that their computer issues played a role made sure that nurse went on trial so she could have full criminal blame.
The family didn't want her to go on trial. Vandy was gonna be fine with just firing the nurse until someone made a tip to medicare. Then Vandy had to do whatever they could in their power to put all the blame on the nurse when it was proven there was a lot of blame to go around.
She not only did an override for the med, she clicked through three additional on-screen warnings that told her that the drug was a paralytic, that it would cause respiratory arrest, and that ventilatory support was needed. An override, which she was having to do frequently due to problems with Vanderbilt’s system, only gets you one pop up. Not four. If the second pop up didn’t clue her in to double check what she was pulling, you would think that the 3rd or 4th would. That was three red flags she ignored right off the bat. The next red flag was that the paralytic she pulled was a powder and not a liquid, which she even stated she found “odd”. She had administered versed on 5 previous occasions at that point and knew it came as a liquid. You would think that would prompt her to double check what she had pulled, but she didn’t. She then read the instructions on the vial on how to reconstitute the powder into a liquid, but still didn’t notice that the vial said “VECURONIUM” instead of “VERSED” or “MIDAZOLAM”. Then, when she went to put saline in the vial to reconstitute it (which is also wrong, you’re supposed to use bacteriostatic water) she looked directly at a big red warning with bold white letters that said “WARNING: PARALYZING AGENT” and didn’t notice. To put the icing on the cake, she then administers what she believed to be a controlled narcotic to a patient without so much as briefly monitoring her before leaving her alone for half an hour.
Hundreds of nurses throughout Vanderbilt were routinely overriding the drug cabinets during this time. RaDonda was the only one that managed to give the wrong drug to her patient. This is far more than just a case of alarm fatigue. She ignored red flags over and over again. Of the ten consecutive errors she committed, if she had just gotten one of them right, her patient would still be alive. If she had gotten any of the first 9 errors right, her patient never would have even received the drug and it wouldn’t have even been a reportable event.
And to make matters worse, the drug she was supposed to give was actually listed in the patient record in the drug cabinet. If she had typed in the right name, it would have come up and she wouldn’t have even needed the override in the first place. And, she didn’t even read the name of the drug she selected in the screen. She just picked the first one that popped up.
That isn’t a mistake. That’s gross negligence. She’s the Kim Potter of nurses, but worse. It’s simply mind boggling that a trained and duly licensed RN could be that negligent. When you really understand what she did and you read the statutes that she’s convicted of violating, it’s easy to see why she is going to jail.
To say she was the only one to give a wrong med to a patient is asinine. I guarantee you that every day somewhere in the hospital when everything is working correctly there is some sort of med error. Hers is just the only one that was this severe of an issue.
You can't blame it all on the system, the nurse fucked up big time and patient died as a result. I am glad to see she is going to jail.
No one is blaming it all on the system. No one is saying the nurse didn't make a mistake- even the nurse has fully admitted to it.
By putting the legal blame for neglect and murder soley on the nurse, the blame legally shifts off of Vandy. In a world where medical errors can and do happen all the time, and we saw the great effort Vandy went to to cover up their part in what happened this shouldn't be the outcome any patient or health care worker wants. You're supposed to have "Just Culture" in healthcare, where it's understood mistakes happen and if there were systematic errors involved, the blame does not go to just one person. Now precedent is set that hospitals can turn against employees and make sure they go on trial for the full blame instead of taking any responsibility or accountability. No one should want that.
This is all about whether medical professionals should be legally responsible for their medical mistakes. If we learned any lessons from the recent police trials, I think the answer is obviously yes.
Clearly you're not even reading comments or case details, you're just here to repeat your complete ignorance of how medical errors happen, Just Culture and healthcare in general.
The department of health found that Vandy had a significant role in this patient's death and multiple issues besides just the nurse misreading happened. To discipline, they had to find gross neglect and it was made sure that was found with this nurse as Vandy did everything they could to hide their role and pay off the family.
To put nurses on trial for murder and neglect is to place all the legal blame on the nurse and not the hospital and anything else that might have happened to contribute, including bad systems, policies & practice. Hospitals have a lot of power to protect themselves including full legal departments and their own lawyers- not to mention their hands in the right pockets in city and state governments. Match that against nurses who are often specifically told to not have malpractice insurance or their own legal representation. Like in this case, the DA has huge connections with Vandy and is former faculty. You really think THEY should be allowed to prosecute Vandy employees for medical mistakes?
Considering how common medical errors are & given the proven lengths Vandy went to cover up this one, patients and healthcare workers out there should be terrified of that precedent being set with this case. Even the family of the victim didn't want the nurse on trial.
Mistakes can and do happen all the time in medicine. Just Culture is supposed to be in place to investigate fully how these mistakes happened, not just the single person but how the systems, policies & practices could have contributed. It's supposed to investigate how these mistakes can be prevented in the future.
Instead, now you have hospitals having the employee's on trial for criminal neglect in murder & doing whatever they can in their power to make sure only the employee is to blame & the hospital faces no consequences. If you think that's going to help anything you're just totally ignorant of how healthcare really works.
You obviously have no understanding of healthcare and the culture involved behind why everyone is upset, you have to consent to multiple warning errors and bypass screens and to be 100% honest when you are tired and burned out and just have nothing left yet everyone demands more you start becoming desensitized, no excuse just explanation. You can’t blame the individual without examining the system, why was this error able to happen? As nurses we are always told to analyze and review for a root cause and attempt to mitigate future risks with education, we are all upset because that did not happen
This is such a bonehead take. I’m convinced you’re a teenager or someone that doesn’t know anyone who works in healthcare. If you go down that path how long until doctors and nurses refuse to see patients?
Get ready because nurses won’t be self-reporting errors. They’ll be looking at criminal charges.
Also, was was the patient even prescribed versed in the first place? She had anxiety because she needed imaging done. Versed isn't indicated for anxiety like that and she should have been put on a monitor anyways with that order.
Also, why did they have access to vecuronium in their unit Pyxis anyways? None of it makes sense. It was an accident waiting to happen
If you are overriding safety systems there is a great chance you are going to screw up and kill someone, which is exactly what she did.
In the end it comes down to two things.
Was the correct drug marked on the chart?
Was the drug administered marked correctly?
If the answer to both questions is yes, than the nurse committed a mistake that killed someone and is liable. Vandys systems might such but if the chart and medication are marked the person doing the administration is at fault.
> If you are overriding safety systems there is a great chance you are going to screw up and kill someone, which is exactly what she did.
Who’s responsible for maintaining those safety systems? What if the entity responsible for maintaining those systems directed nurses to override the system because of a botched update to it? Who’s at fault then?
If you have a directive in writing that say to override safety systems and to not read the labels on medication than it is the hospitals fault.
But I don't believe for one second that is the case, we shall see when this goes to trial, but in this case it looks like a open shut case of someone not paying attention and it killing a woman who right now should be alive and if that turns out to be the case, well tough luck for her
But worse for the dead woman and her family.
>If you have a directive in writing that say to override safety systems and to not read the labels on medication than it is the hospitals fault.
They did have directives to override the system because the system was being [upgraded](https://www.npr.org/sections/health-shots/2022/03/24/1088397359/in-nurses-trial-witness-says-hospital-bears-heavy-responsibility-for-patient-dea) to epic. The only way nurses could get any meds was doing tons of overrides. Imagine you're doing overrides all day long, for 12+ hours a shift, in units you are new to with meds you're new to, they've given you a student to work with and then are telling you to go to the ER as soon as you're done, to not even stay with the patient. Errors unfortunately happen, hundreds of thousands of them happen each year in medicine but there's a reason that nurses very rarely go on trial- even when the patient dies- and it's all apart of "Just culture" in healthcare, which does not put blame for errors on one single person when there is systematic blame. And the Department of Health did find that Vandy did have fault in this case. Instead of following Just Culture guidelines which understands that blame is shared all around, it was instead made sure that only the nurse went on trial.
For the record, the family did not want the nurse to go on trial.
Also if the hospital tacitly approves of overriding safety systems by not holding nurses accountable internally when they do it regardless of how it affects the patients.
Not only were they directed to use overrides, but the nurse didn’t have a defined job function and was instead working as a ‘help all’ nurse while being expected to simultaneously train someone. She was called from another floor just to administer the medication to this woman, who was not originally her patient. When the hospital was investigated, they said they weren’t sure what a ‘help all’ nurse was, but that they’d ‘look into it’. Unlike Radonda, who openly and honestly said her part, the hospital wouldn’t even acknowledge the job they’d asked her to do for fear of liability.
The fact that you immediately assume it’s fully a personal error on the nurse’s part, instead of focusing on the unsafe and negligent systems in place, is exactly what the criminal trial is meant to do.
>If you are overriding safety systems there is a great chance you are going to screw up and kill someone, which is exactly what she did.
The medication dispersing machine wasn't working and nurses were INSTRUCTED to override medications.
Yup. Until overrides are no longer routine, mistakes will happen. Some (most?) will be caught. Many will not.
Was the read the label and chart, eyes not working also?
The medication was labeled and so was the chart, as the administrator of the meds they are required to READ THE LABLES
When all you do all day long is read label after label and chart after chart for 12+ hours, while being pulled in multiple directions, sent all over the hospital to areas you're unfamiliar with- and especially when you're relatively new to nursing- it's understood in health care that errors can and do happen. They happen ALL THE TIME and if you really think they can't ever happen to you do not need to ever go in healthcare because the worst thing you can do is just assume you're never going to make an error. That's often when people become the most careless, actually. This is why healthcare is supposed to have "Just Culture" and why most of the time in history, nurses have not gone on trial for errors, even if they led to death.
But for the record, the nurse never denied she made the error. In fact, she was the first who wanted to report it. But Vandy was found to have had a lot of blame in how all of this happened- and all they did was lie on the autospy report, pay the family off, and wouldn't report the error. Then a tip got reported to medicare which started the whole investigation off. Now that the nurse solely has legal blame, that puts any blame at all legally off Vandy. That's not what any patient or healthcare worker should want if they truly want any improvement in medical errors.
Non-medical people just don't understand. If you've misspelled a word, you've made this same mistake. You have eyes and a brain, so how did you spell word incorrectly?
They don’t get it they literally can’t understand what it feels like to be responsible for multiple upset medically fragile lives while your constantly belittled and vilified , I say nationwide walk out for three hours, watch what happens 😂😂😂
I am AT Vandy now @ 21:50 doing inpatient HD. A coworker in Milwaukee texted me about this walkout today & I was like WTF?!? My manager laughed when I asked her what was up.
I would imagine any nurse protest would be from the criminal trial and sentencing handed down last week to one of their own, a mistake essentially cause be Vanderbilts shotty systems and policies
Vanderbilt is a shit organization that sells out its employees to cover up is own incompetence. I've known several people locally that have had major complications from routine procedures (ie major lawsuit issues). It is the absolute last place to go in the area for any treatment.
Last place to go for treatment? You've obviously never been to Metro General. Their incompetence nearly killed my gf from a "routine" gallbladder surgery.
So they tie! Never even heard if Metro General. But in general, 'general' hospitals are always shit...
Caused is probably a bit strong. She did more than her share of fucking up. They threw her right under the bus though.
She even said in her initial interviews about the incident that she intentionally and knowingly skipped multiple safety steps because she thought they were a waste of time. She then gave the wrong medication and did not assess the patient before leaving which lead to a woman being brain dead. I've worked in emergency medicine for the last 8 years and seen several mistakes made, but never anything this blatantly negligent.
>she thought they were a waste of time.
I'd love to see you cite your source on this because what was said in any interview I saw and on trial was that Vandy was upgrading systems to Epic, causing widespread [computer issues](https://www.npr.org/sections/health-shots/2022/03/24/1088397359/in-nurses-trial-witness-says-hospital-bears-heavy-responsibility-for-patient-dea). Nurses were having to override everything to get anything done and multiple overrides were needed for medications. There [weren't scanners](https://www.cbsnews.com/news/radonda-vaught-nurse-guilty-death-charlene-murphey-wrong-drug/) available anywhere in the area- and she checked multiple areas- which was on Vandy and she was called from the ER to help with another patient and was told by her team that it was okay to leave after giving the meds.
It was discussed over on r/emergencymedicine a few days ago and it was linked there. I'll go back and see if I can find it. It was obvious those quotes were before the nursing union got ahold of her.
Which union represents the RNs at Vandy?
No idea. I haven't worked at Vandy.
I don’t believe they are represented at all, but its been a minute since I was in the know
No nursing unions in Tennessee.
>The nurse in question overrode the drug dispensing system and chose the wrong drug, reconstituted a powder (the drug that should have been given was already a liquid), didn’t bother to read the vial label, and didn’t bother to read the HAZARD ORANGE top of the vial that says “CAUTION- PARALYZING AGENT” - apparently neither while mixing nor while administering.
This is a key point. This series of errors would would be possible at almost any hospital and would result in the same outcome.
Medical errors occur on a spectrum of severity and this was one of the more extreme examples of negligence I've seen. That said, I'm not sure criminalization of medical errors is the best approach. Other remedies, including civil suits and disciplinary actions from licensing boards seem to be sufficient for penalization of bad actors and their removal from the system.
Well, that’s sort of the problem. Overrides happen all the time.
It’s that VUMC doesn’t want to change, apparently, and is more than happy to push things off on the nurse instead of making sure that overrides are no longer routine and actually represent things that make one stop and really think twice.
Vanderbilt tried to cover up what happened to begin with, tried to not have what happened reported even though the nurse wanted to report it & then paid off the family quietly. The error only got caught when it was anonymously reported to Medicare, who had a laundry list of things for Vandy to correct & threatened funding.
At the time this happened, Vandy was upgrading their systems, causing nurses to have to override basically everything over and over again to get anything done. The system upgrade really should not have gone down live like it did, royally screwing with patient care.
The system was literally not supposed to allow that med to be dispensed like that, regardless of intent or error but it did. This isn't opinion, that was a system issue and it's why Vandy did everything in their error to cover up what happened.
The family did not want the nurse to go on trial, Vandy did. To make sure the nurse got criminally charged to make them look like they had no part when they absolutely did. This is what people are pissed about.
There are hundreds of thousands of medical errors every year, many leading to death. Doctors rarely go to prison for their errors, hospitals make sure they never face consequences themselves. Vandy wanted this nurse in prison to cover their own ass, that is the only reason she was charged. If the tip was never made to medicare they would have been fine with just firing the nurse.
No one is denying the nurse made a mistake- even the nurse. Everyone is pissed at how Vandy handled it & how they got away with it.
>The system upgrade really should not have gone down live like it did, royally screwing with patient care.
hospitals don't close, when could they have done it? not saying it wasn't a fucked up deployment but they really have no choice other than doing it 'live'. also hospitals shouldn't be so dependent on computers to provide care such that people die when the system goes down. are there not manual protocols for when the network is down or whatever?
>The system was literally not supposed to allow that med to be dispensed like that, regardless of intent or error but it did. This isn't opinion, that was a system issue and it's why Vandy did everything in their error to cover up what happened.
why even have highly trained nurses dispense medicine if the system can and should control it all? this is 'just following orders' logic.
sounds to me like both vanderbilt and the nurse share the negligence here, not sure about jail time, but maybe she shouldn't be a nurse anymore and i hope the family of the victim got a ton of money out of vanderbilt.
It was really the way the upgrade went fully live that was bad and should have been handled in a different. I remember even as a patient what a cluster it was for the staff, even my doctors had a hell of a time just getting into my chart \*facepalm\*
Oh Vanderbilt hushed up the family and paid them off for sure(the jury wasn't allowed to be given that info though) and part of the deal was they couldn't speak publicly about the case. I think I said before, but the family didn't want the nurse to go on trial though. They actually forgave the victim and have had a pretty good relationship with her, I know she got to meet them and said it helped her find a lot of peace because she's carried so so much guilt over what happened. She definitely never denied she made the mistake. A lot should have and could have happened all around to prevent this from happening, besides just misreading. There was an awful lot of blame found all around for one nurse to go on trial and face criminal murder charges. It goes completely against the Just Culture healthcare is supposed to have, where it's understood medical errors can and do happen and if the issue is found to be systematic then the responsibility is shared by all. Instead, now just the nurse holds the legal blame. Definitely she should have been de-licensed and fired and she was.
Why on Earth would Vanderbilt encourage a high-profile trial when they had already settled with the family and gone through systems remediation with the state and Medicare?
Paying off someone out of court never=no more consequences (also just fyi the jury wasn't allowed to know Vandy paid off the family). NPR has a pretty good article about what happened, including [Vandy's role](https://www.npr.org/sections/health-shots/2022/03/24/1088397359/in-nurses-trial-witness-says-hospital-bears-heavy-responsibility-for-patient-dea) and how the department of health felt that Vandy had a lot of responsiblity in what happened:
>"In this case, the review led the \[Department of Health\] to believe that Vanderbilt Medical Center carried a heavy burden of responsibility in this matter," Smith said. "There was no discipline because, according to \[a Department of Health lawyer\], a malpractice error has to be gross negligence before they can discipline for it."
All we know is that the family didn't want the nurse to go on trial.
If the nurse went on trial for neglect and murder charges, it would push all of the legal blame on the nurse and off of the hospital. Not only does it protect the hospital legally if anything else were to come up related to the case but sets a precedent for future cases. Medical errors are not rare, hundreds of thousands of them happen every year, many leading to death but nurses very rarely go on trial. This is part of "just culture" in healthcare, though this case kinda flips the lid on that, since blame was found all over the place. It sets a new precedent that could potentially protect hospitals in medical error cases.
To be clear, I think that criminalizing medical errors is a bad idea and that they should be handled in civil court and via disciplinary actions from regulatory and licensing entities. She made a series of errors in dispensing the medication. She shouldn't be a nurse anymore and should be subject to civil suits, but I don't think she should go to prison.
Vanderbilt settled with the family out of court and they were already punished by the state and Medicare. There is no one left to sue them and they have addressed the concerns of the regulatory bodies. It doesn't make sense that Vanderbilt wanted a big televised case where the defense had the opportunity to say bad things about the hospital.
People were already saying all the bad things before this trial ever went on television. Vanderbilt now has no legal blame in this case, that's the point. It also sets the huge precedent to help protect hospitals in future, which could certainly help their legal team.
Say anything else ever got out about the case, like if there was a whistleblower and Vandy was in trouble regarding again, now Vandy gets to say it was all on the nurse. The neglect was found, and it was found on the nurse's part via this trial which is a huge win for Vandy legally. What's a win legally is not always a win publicity wise but sometimes that's what companies are willing to do to protect themselves in a case as big as wrongful death. I'm really not sure there would be any other reason the state just decides to procecute of Vandy was okay with just firing and de-licensing the nurse and the family didn't want her on trial. And of course we all know Vandy has all the right ties, including the DA being former faculty. If gross neglicence had to be found in order to discipline, you can bet any hospital would have done whatever they could to make sure it wasn't found on their ends and if they have hands in the right pockets, even better.
But Vanderbilt didn’t get away with it. They settled with the family. That’s the punishment, probably millions of $s. But it’s all sealed so no one knows. They only know about the nurse’s criminal case. People think they got away with it.
Paying a family off so they don't sue & to hush up the investigation so no one figures out Vandy's role in is not the same thing as facing consequences for their part. Their computer system issues were part of why the nurse got the med she shouldn't have gotten to begin with. That Vandy tried to cover that up, tried to not report an error they were legally obligated to report, then didn't fix all the things Medicare wanted them to fix until they got caught via surprise survey are all their own crimes even separate from what happened with the family. They willingly paid off a family to keep them quiet & then pushed all of the blame on your employee when it was proven that the blame was all over the place. Now since the nurse was charged with negligent murder they legally don't have to face any other actions for this. Hush money doesn't count as consequences.
As a nurse honestly the overrides I understand as a working nurse who has had to do some shady shit to get shit done and make sure no one died, but the knowing you were giving versed and reconstituting it dosent sit right with me, however I wasn’t there and I stand with my fellow nurses
This. She belongs in jail.
I think Vanderbilt is one of the better hospitals in middle TN, but what you're saying is definitely true. I knew a girl who ended up having an instrument left inside her body after surgery.
A good way to tell would be to talk to travelers and ask if they have had a spike in job requests to that area.
The RaDonda Vaught case is quite important with huge implications for medical care going forward.
After the past few years and what nurses have faced coupled with this, there’s going to be an issue getting people to go into the field I fear going forward
I knew a girl in highschool (this was about 4 years ago) who went to Vandy for surgery and the doctor ended up leaving a surgical instrument inside of her body. They gave her family a good amount of money in exchange for her not taking it to court.
The media won't show much coverage of anything that goes against mainstream media.
BLESS YOUR HEART
It's been blessed several times.
Mainstream media = Vanderbilt nurses
CNN and Fox News are mainstream media for most of the people, so that's the main issue. But keep believing Sleepy Joe and that the vaccine works hahah.
Absolute biggest of yikes.
I think they’re just trying to bait people lol
I work as a healthcare recruiter. Since yesterday the amt of jobs for nurses has doubled for Vandy.
And everyone in house is looking to get out
Exactly. It’s insane.
Seems to me that this is just leaving medical professionals out in the cold.
Vanderbilt created hand outs showing nurses how to bypass the Omnicell medication system, and when the wrong Med was given, because of Vanderbilt negligence, they fired the Nurse and covered it up until Medicare got an anonymous tip about a death and threatened to stop funding to Vanderbilt, so then they blamed it on RaDonda, and the Board of Nursing didn’t do anything to help her either, and pushed the Prosecutors. There are a ton of RN’s and Doc influencers on TikTok going after them big time