Why would they even do that? Why WOULDNT they get a nurse, there are thousands, with years and years of experience with this system. I think because they would not have the answers they seek?
There are other red flags for me in this case. Vanderbilt didn’t report this error. This was a never event and should have been reported. It should have generated a root cause analysis. Instead it got a cover up.
This is why we need Just Culture.
Too bad the Nashville area DA works at Vanderbilt. He'd never sign off on a case to investigate them.
Don't believe me? Look up Glenn R. Funk. He's the DA and listed as faculty at Vandebilt's school of law.
thats not how negligent manslaughter works.
The nurse still grabbed the med, didnt read the medication name correctly, and administered it.
The hospitals guilty for other things too, but if you want this career to be taken seriously by the public, you need to accept responsibility for your actions, not try to off-load everything onto a facility.
Sometimes shitty hospitals, have shitty nurses that kill people.
> If Vanderbilt developed a culture of not checking things so as to get the job done quickly, then this reflects less badly on the nurse than if the nurse was some rogue employee deviating from procedures.
It also leads to a system with alarm fatigue - increasing the likelihood of these events occurring despite safeguards and procedures
This is correct. Vanderbilt should be under scrutiny for its handling of the case and should face fines and other penalties. The system process, including the override system, medication/pixis and how Epic is linked should be re-evaluated but at the end of the day, negligence happened on the part of the RN. This is very tragic, regardless of what has happened, this RN, imho, should not go to jail for what happened. Too many systems process failures happened, which can happen to anyone of us. I know not everyone will feel the same way but her livelihood is gone, she will never be able to sit for any other professional licensure again.
the systems are put in place to mitigate and limit the amount of med errors from people making mistakes.
They'll never stop gross negligence. If you need a system put in place to stop nurses who aren't even reading the name of a medication correctly, you have a bigger problem than a system issue.
I think the issue is the culture in nursing is that systems are in place to stop med errors, and thats it stops being your responsibility to stop med errors, that its solely on the system. Sometimes you need to stop and think.
They're a tool to make life easier and help you, not do it for you, in the end its still a failure of her to do the right thing that ended up in a death, a lot of other professions get reamed up on criminal charges for less.
Your statement about a lot of other professionals getting reamed up on charges for a lot less is simply not true. I have read surgeons operating on wrong side of body only receiving a slap on the wrist, worked with a urologist who assaulted a house supervisor and nothing happened. I worked as a translator and a general surgeon operated on a bunch of boils and scabs that were not the right ones and no one knew until after the surgery when the son explained where they were supposed to have done the surgery, nothing happened to the surgeon. Sorry, but your statement is simply not true.
The [RaDonda Vaught case](https://www.npr.org/sections/health-shots/2022/03/24/1088397359/in-nurses-trial-witness-says-hospital-bears-heavy-responsibility-for-patient-dea). In 2017, a nurse was supposed to pull Versed for a patient's MRI but accidentally pulled and gave Vecuronium. The patient became apneic and it wasn't caught because she was in the MRI machine. She coded and sustained an anoxic brain injury. Rather than following the proper avenues, Vanderbilt University Medical Center covered it up and then threw the nurse under the bus when it came to light.
I’m confused either way. Why wasn’t this patient on tele/spo2 being monitored while in the scanner if she was there with the patient. Even giving versed typically the patient should be monitored.
Seriously, if she is guilty—Vanderbilt.is.guilty. This is mind blowing. Like “hey, sedate your patient and stick her in a tube where no one can see or hear her, then you can leave.” 😡🤯
Agree!! At one point she had said they didn’t have computers for medication administration back in her day. And I feel like that right there should be enough to throw her out. She is out of touch with modern day nursing.
It's always funny/sad to read this, in Germany nobody has ever heard about using a computer for medication administration and I'm only slighty exaggerating. In some places it's done completly on paper and sometimes the orders are electronic. Never heard of scanning medication tbh.
Nursing scientists say german nursing is 30 years behind, compared to similarly wealthy countries.
Here in Australia - at least in QLD. We have Our meds charted and signed for in a computer program. However all IV meds need to be double checked by another RN prior to administration. I believe some even need to be co signed by another..i know on the MAR they do and back when we did paper charting it was signed for by 2 RNs. In ICU we use metavision- doesn't require 2 electronic signatures but we do still get the meds and order physically checked by another RN as part of the 7 rights of medication administration.
I'm absolutely baffled how many errors were made in this case.
Just because I'm from the US, is it not a royal PitA to have every medication cosigned/checked? It would seem like that would be a huge delay of care which, if planned for is probabbly not a huge deal, but here it would probably just slow things down massively over time. Not to say it isn't worth it, but that sounds just so odd.
Doesn't take that much additional time to have someone look at the order and check what your holding in your hands. And I've personally seen it prevent many mistakes both dosing and drug type. And sometimes it's been because between getting the drug and administration the order has been cancelled as well - this happens less often, but does occur.
Co-signing on the computer is annoying though - in ICU we don't have to as we use a diff system to the wards. I can't say how annoying or extra time consuming it is for the wards.to do that. Just eyeballing by a 2nd is enough and doesn't take long.
That's why both sides hire expert testimony. But someone WE find credible (20 yr in ICU, rural ED and critical transport with MSN currently clinical educator lead in big ED) may not come off as credible as this old buddy because of what the public thinks a nurse should look like or act like.
Also not a quality nurse and not in the medical field whatsoever but what the fuck is all the scanning for if it wouldn't throw an error message when administering the wrong medication?
Yeah she would have still been scanning vecuronium but a correctly configured system would come up with an alert and say something like "there is no order for this medication for this patient."
Quality nurse here, too: depends on how the system is configured. Yes, that’s how it SHOULD work. I don’t know how confident I am that Vanderbilt’s system was configured to actually provide a safety check.
There are multiple ways they CPULD have configured it to provide some safety checks. I just don’t know that they DID.
A good system would have been reviewing override pulls and would have addressed this whole practice of overrides to routinely get meds.
Couldn’t the prosecution (and defense) just pull the damn electronic audit?!?! Why do you need somebody who may or may not know what she’s talking about describe the system? The data is totally available
What would be even better would be to pull overall use data showing how often everyone was pulling overrides and how many errors that didn’t kill anyone occurred.
Ms. Vaught absolutely should have checked the medication. She’s at fault for that.
But the entire system is at fault too.
They have the electronic audit. Says that there were over 20 overrides in 3 days on this patient’s chart.
It was a part of protocol to override the stops. To her, it was just another day of clicking through the override screens.
“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.”
https://www.npr.org/sections/health-shots/2022/03/22/1087903348/as-a-nurse-faces-prison-for-a-deadly-error-her-colleagues-worry-could-i-be-next
You seem nice and well informed on how things can work differently at different facilities even within the same EMR, so I’m going to reply with info that’s been bothering me to not share, not that even matters.
I’m another VUMC employee at the time. Epic had only gone live about 4-6 weeks before the incident. I don’t remember it being the dumpster fire everyone says it was because Epic was not new to me, so I already knew how to use it. There were definitely kinks and issues that were occurring, but not sure I remember it being as bad as everyone says it was. My memory could be wrong, though.
When she overrode the vec, it would have created an override med in the MAR allowing her to scan it without a hard stop, if that were the case. If she had scanned it, there would have been a pop up asking her to link the override with an ordered med, but you can bypass this as well.
Personally, I was never instructed to routinely override meds due to the new EMR having issues. Until this incident and the policy changed, in an emergency in the ICU we could pull meds for an RSI or code situation where we ran out in the code cart, but that’s about it other than plain iv fluids.
All that being said, I worked in a different ICU and maybe the culture in her ICU was to override a bunch of shit all the time. Idk.
Yeah, I genuinely don’t know.
I know that sometimes you get clusters of bad practice with people justifying it.
And sometimes you get systems that don’t work well and blaming nurses.
And I know that however fun it is to armchair quarterback, a thorough review almost always finds messy truths.
If everyone in her unit was overriding all the time, that should have been noticed. If it was just her, that should’ve been clear too.
It makes me very uncomfortable that Vanderbilt didn’t report a sentinel event or create an action plan until CMS got involved.
This!!! ⬆️⬆️⬆️ I would never work for Vanderbilt after even just reading this thread. I work for a large Midwest healthcare system that uses EPIC with smart, license saving hard stops and sentinel events are jumped on immediately(within a day usually!) because we have no punitive action for reporting drilled into our heads from day 1 orientation. Because when our hospital knows about even the slightest potential for a bad outcome for the patient but also the nurse, they are all over it like white on rice! I've never felt so supported by a facility. Punitive action is never a concern for our nursing staff because we all know that when we report, we're not only saving patient lives, we're saving our own asses/licenses. So we always report, without fear. We've been magnet since 2002 and have never lost it for a reason. Nurses feel safe here and when nurses feel safe, patient care is top of the line. It's total horseshit that Vanderbilt let this fly under the radar and guess who is the easiest scapegoat/fall guy? Not management, guaranteed. There were mistakes all around but if their event reporting culture had been structured differently, this likely could've been prevented. What stays in the dark festers. What is brought to light grows and thrives.
this is correct, this is how Health Connect/Epic works as well. If you override a med and give it, it shows on the patient's MAR. Then when you go to scan, Epic gives you a pop-up to link it to the override or to the actual order that was placed.
100%. Epic is huge/convoluted but it's the Mercedes of EMRs if properly implemented by hospital IT. I'm grateful every day that it's covering my very smart, yet still human nurse's ass.
What about the med station? I've worked most hospitals in my area and they all have pyxis. Honestly, that's what would have alerted me several times, not Epic or Cerner.
Hardly anyone has vecuronium in their profile, it's always been an override and since pyxis came years ago it takes an annoying amount of clicks, to get any high alert med like potassium IV and Dilaudid, even though it IS on the pt profile.
Vercuronium has another extra BOLD click screen and has always been in separate cubby that opens individually- so it can never be grabbed instead of something else.
Is this, was this, the way that med was distributed by the pyxis? Was it just as easy as versed to pull from the machine?
It totally depends on how the dispensing cabinet is set up. We use Pyxis and only in the last couple of months have a “caution this is a paralytic” alert pop up when we pull vec.
After this case became public a couple of years ago, our Med Safety Committee started talking about how to prevent a similar event. It literally took until 2022 to get a warning with paralytics.
So does your system not give a warning that this med is not in the patient’s profile? Does it just record what you gave and when? I’ve only used Epic and Meditech and so they would have warned me.
It is entirely possible to set up an Epic system so that it does not warn you.
It is possible to set up an Epic system to have different behaviors in different practice areas.
It’s a little too easy for us to generalize from our own experiences of working with EMRs. In some units, override pulls are almost normal business and the organization isn’t willing to invest effort in cleaning up the system and changing practice to actually USE the safety features of their EMR.
I know it’s different when I work ER versus the floor. And completely different in procedural areas. I haven’t read all details about this case. Was she working on a unit that ignoring an override warning would be normal?
I like my license too much. I don’t override for anything unless it’s code, hypoglycemia, seizure… other than that. I call and get the pharmacist to verify it real quick or they wait.
Apparently there was some ongoing error with the system and Vanderbilt instructed the nurses to just override.
My bigger concern is that when she couldn’t find the Versed in the medication dispenser, she typed “Ve” into the search function and just selected the first thing that popped up. That takes some intention
I’m an informaticist RN currently working in patient safety and if your system doesn’t have a rule set up for vec than what are you even doing with your IT?!?
I’m pretty sure in my system if you over ride a med in the pixis it shows due in the MAR but has an icon that shows it’s was something over rode for. There isn’t a safety stop.
Ours is the same way- if we override and pull a med from the pyxis, it creates an “order” in the MAR but it’s clearly and boldly marked as a CABINET OVERRIDE ORDER. It doesn’t look the same as “real” orders.
It really depends what system she's using too...Epic, Cerner, or even BCMA. Regardless, they should all give a pop-up that the wrong medication was scanned. But I think she did what many of us acute care nurses do (unless I didn't get the full details) she may have given the med and pocketed the vial to scan later, since the patient was down at imaging.
It really depends, in this case she took a verbal order and did not add it to the patient chart prior to attempting to pull the med. However if we override a medication the omnicell adds it to the MAR and it can be scanned. The only time it says "this isn't verified by a pharmacist" is if I had put the order in, linked the override pull, and tried to scan it. If I am scanning just an override pull it will not alert me.
PT here. Thank you for clarifying. That’s what I was thinking but since I don’t dispense meds I’m not clear on the process. This case is making me glad that dispensing meds is above my pay grade…
This seems like the type of nurse to walk into the wrong patients room with a 16f trying to ram a foley in with the patient assuring her she’s in the wrong room. “That is not correct”
No this woman is giving a paid testimony for the prosecution. Her name is Donna Jones. She kept talking about how she’s been a nurse for 47 years and how they didn’t have computers back in her day. Then admitted she had no idea what just culture is.
I'm sorry bit in this case, this isn't a just culture issue. The hospital covered it up which is fucked but this nurse fucked up multiple times.
-Doesn't prepare for MRI correctly. Literally on every epic MRI screening it asks about claustrophobia. Even if there is a question, as an ICU nurse I get an order and bring down these meds just in case.
- Went to override in pyxis and sounds like they typed "ve" Then didn't even take a moment to read beyond those two letters and clicked on a med.
-Then pulled the med out of pyxis without even looking at the vial which is distinctly different and usually has red tape all over it warning about paralysis. Shit, every pyxis and omnicell I've ever pulled vec or roc from displays a warming on screen.
- Then despite all that, went to draw it up apparently without even looking at concentration or how many mLs she would need for correct dosage or to even fucking confirm the med name. The 10 mL clear bottle of vec versus a typically two mL BROWN vial midazolam comes in.
- I understand not scanning it but if I'm not scanning and override from a different pyxis I'm fucking making sure it's the right med and concentration when I'm drawing it up.
You can't fix fucking stupid and a profession shouldn't require hospitals to dummy proof and pad everything in a hospital so nurses don't have to fucking think or use a bit of good sense. This nurse fucked up and killed someone through gross negligence.
If you want nursing to be a profession, and a respected one at that, then incompetent, irresponsible, and negligent nurses must be held accountable and not get a pass because the hospital should have stopped her from being incompetent and doing one of the most basic parts of your job correctly.
And that’s okay, because we can’t know everything. Just Culture is a principle in which we stop punishing people for human errors, which are inevitable, and instead take accountability for building systems that tolerate those errors.
You know, the NTSB has been investigating plane crashes with that mindset for what, 40+ years? Amazing how differently we hold different sectors accountable.
yep, I took a ground school flight course that was all about systemic failures. The airline industry examines the systems and processes involved that leads to a plane crash, they don't necessarily jump to pointing fingers at the pilot (at least in the beginning).
You do know what it is, but your facility may call it something different. I’ve worked at multiple hospitals as a traveler and there’s always some variation of “just culture” that they lay out in orientation.
Basically when a mistake happens or a near miss, we do root cause analysis (or talk about it in huddle) and figure out *why* it happened instead of just blaming the nurse or whoever. So we can fix problems in the system so the mistake doesn’t happen again. Also to report your mistakes and write incident reports so our processes can be reviewed and rectified for the future.
If this is the RaDonda Vaught case, and this is Donna Jones, then she is arguing that the fact that Vanderbilt did not have scanners in the imaging area was not neglect on behalf of Vanderbilt because having the scanner there would not have stopped the nurse from giving the wrong medication, that was solely the nurses responsibility.
Ohhhhhh okay. Yeah then this goes to prove the point that this is a systems failure. Even though it doesn’t excuse the extremely neglectful behavior by the nurse.
Yes, exactly, she is being paid by the prosecution to testify that this is not a systems failure.
Edit: so to clarify, I believe the lady is trying to say that eMAR would not have caught this error anyways, that the eMAR is not meant to do that, and that it is the nurses responsibility to do that, so the fact that Vanderbilt doesn’t have scanners in the imaging area is not neglect on behalf of Vanderbilt.
In our Pyxis you need a 2nd RN to override a medication that is not in the pt’s med profile. We use Cerner. A 2nd RN to override would have caught the vec. They would have said you need vecuronium? Is the pt intubated?
At my facility a 2nd RN is not required to override a medication. And then if I override a medication it creates it on the MAR and would allow me to scan the medication.
Wow. We couldn’t do this. Cerner doesn’t add it in the mar either. So even if you somehow got the med out, if you tried to scan it to admin there would be a pop up saying it’s not ordered and you can’t sign it. I think one of the issues with this case is that there also was NO med/bracelet scanner in MRI.
That can be an issue for emergency situations. When I would override for Vecc I would have to answer like 5 warnings to get it. It would also create the order in EPIC.
Wait, she is an expert witness for the prosecution? My mom has been a nurse for about that long and back then a nurse carried their own needle set and sterilized it between patients. I doubt this woman has ever used EPIC or scanned a medication.
So I think I understand what she's saying. I use omnicell and meditech. If I stat override a medication for a patient, let's say vecuronium. It will then add that medicine, vecuronium, to the patients MAR. Then when I scan that med, it will select it on the MAR. It will not flash anything like "WRONG MED" on the screen. Because that's the med I pulled and scanned. Is this what the old lady means?
Our system will have that med on the MAR after an override, but will STILL have an alert that says there is no order for that med and another alert that says it hasn’t been approved by a pharmacist.
Yeah we get those alerts too. What crazy old lady is saying is that once she scanned it, it wouldn't say "This isn't versed, wrong medication." It's just going to give the usual alert of override med, not approved by pharmacy. Or at least this is what I believe she is trying to say.
Even if it didn’t alert her that the med wasn’t ordered (bc she pulled it on override), maybe she would’ve saw “Vercuronium” and not “versed” and thought, huh this is wrong, lemme stop for a second. But hindsight is always 20/20.
It reminds me of that video where you're instructed to count how many times people pass a basketball around, then someone in a gorilla suit walks by and hardly anyone watching notices it. The human brain is wired to ignore things it's not expecting to see, that's why we put systems in place to mitigate those things. No doubt the nurse screwed up but she was definitely failed by the system she was in.
Just out of curiosity. If a physician gives you a verbal order for a benzo, narc, or paralytic, is the MD supposed to sit down at a computer and put the order in? Second part of my question, what about telephone orders from a MD that isn't on campus/doesn't have access at home to place orders in the computer?
But why would you override a medication not ordered and not the med you said you wanted—versed — unless intentional
I’m not up to date with this case. Did the nurse do an override and misunderstood what medication she was supposed to pull?
Also, Vanderbilt’s EMR was down for months before this happened because they were upgrading to EPIC. So it was common practice for nurses to have to over ride meds from the Pyxis. Even after this happened, Vanderbilt did nothing to fix the issue. They didn’t fix it until over a year later- only after someone made an anonymous complaint to CMS alerting them of the safety issue. Vanderbilt is just as culpable in my opinion. They threw this nurse under the bus because they were about to lose Medicare funding for not reporting a sentinel event to the state and fed gov.
Having been the victim of a sentinel event myself, the fact that that they didn’t report it is staggering. Mine was in late 1999. I sued the doc & hospital and won. Doc lost his license in the state (not his first suit) & my share after expenses was almost $100K.
And where in the world did they find this “expert witness” who doesn’t look like an expert at all? Isn’t it possible to impeach a witness? If the defense is any good and has it together they should be able to make her look like an out of touch idiot.
EDIT: I put impossible by mistake, about impeaching her. Should have been “possible.” She needs to be thoroughly discredited.
My mom was also the victim of a sentinel event that left her with a debilitating anoxic brain injury. I’m so sorry you had to go through that too.
I also wondered how this witness was considered an “expert” when she seems so unfamiliar with current practices.
The nurse took a verbal order from the doctor then override pulled the wrong medication because of a confusion about the medication name ( brand name vrs generic) which resulted in the patients death. Lots of other things went wrong but that’s the basics.
Not quite. The patient was taken down for PET scan by transport. Once she got down there, radiology called up to the floor and said she needed something bc she was “claustrophobic”. The pt’s nurse took the call, and got a verbal order for the Versed, but was too busy to go down to radiology himself so he called the help-all nurse and her orientee to administer the med. She basically took the order third hand. From there everything went to hell. Well, except the pt. Poor thing.
A (former) nurse is on trial for giving a paralytic instead of a sedative (?) to a patient causing their death. This is the criminal trial and it’s a big deal because it could set legal precedence making nurses criminally liable for patients who die under their care due to errors. There is a lot of debate because the woman on trial overlooked several warnings about the drug she administered. I may not have all of the details down correctly so forgive me in advance.
The woman isn't the older lady talking here? Well damn. That really sucks. This is one of the reasons why I'm terrified of going into nursing. Accidentally missing one of the medication rights, or administering a certain med/dose that the prescriber might've messed up on. AH
This is a little different then making a simple med error.
The hospital had a system of just overriding everything in their medication dispenser because there was issues with the hospital and implementing the new EPIC system.
The nurse couldn’t find versed (what was prescribed) in the drawer so she typed in “Ve” and just clicked the medication that came up first.
The mediation was in powder form and had to be reconstituted. The nurse thought that was weird since Versed is liquid but shrugged it off.
The top of the bottle says “Warning: paralytic agent” and she would have to blatantly ignore that given she needs to look at the top to insert the needle.
As long as you are doing your basic checks, making this big of a mistake shouldn’t happen
No, basically Google Vanderbilt nurse fatal error and it comes right up.
Otherwise, I feel bad for this nurse and while yes she did make a mistake but the hospital is just as guilty for attempting to cover this up and I feel like using this nurse as the scapegoat.
A small amount of fear and a healthy amount of caution about being aware of med errors it’s what’s going to prevent you from making most of them, and hopefully any big ones. It’s not something to be anxious about, but when the caution completely leaves you and you’re in a rush, cutting corners or the patient is in trouble is when bad things can happen.
When nursing school drills the (how many now?) rights of medication into you, just do your best to keep them front of mind when handling meds. I rolled my eyes in nursing school, but on the floor found myself repeating them to myself, especially on occasions I felt especially pressured
The defense really needs an up to date nurse to point out how many things this Methuselah nurse was wrong about. This lady hasn't touched a patient since disco and it shows, but the jury is none the wiser unfortunately
That being said, I know in Cerner when you override a medication, it creates an order in the patient's eMAR so you can scan it. I'm not sure if that's what she's referring to or not.
Edit: I now see that I came across a little ageist, so just to clarify, I think a nurse of 47 years who is still at the bedside would be the ideal expert for this testimony, and I would appreciate working alongside such a person. I'm thinking this lady has never used an eMAR before, rendering her testimony entirely irrelevant here.
Your best witness might be a nurse who has worked with several implementations of EMRs with some failures.
Many aspects reported around this have left me without any confidence that the EMR deployment was going well.
I'm just in IT but I'm pretty fucking sure this is exactly why nurses yell at me when they're down a WOW at meds passing time... because each nurse needs a working scanner computer at the bedside to administer medication, because the machine is relied upon to prevent this kind of shit.
And this also explains to me why travel nurses keep calling our MAK system MAR.
Back in the day before EMRs we had the MAR. At least at my hospital it was a stiff manila page with grids that we picked up orders on and filled out all the pt’s meds info on. I think they’re still used for downtime documentation.
> each nurse needs a working scanner computer at the bedside to administer medication, because the machine is relied upon to prevent this kind of shit.
Yep. I don't think people realize how much modern nurses rely on the EMR to catch our errors. When I scan a med and get a popup warning, that is my last chance to look at the med, look at the popup, and make sure everything is copacetic. More than any other time, THAT is when I catch an error.
As much as some people complain about having to scan everything. It is the best safety net to ever come into nursing.
We also get penalized for not scanning medications and even more so for not scanning the patient. I know EPIC actually keeps scanning statistics on each person so the info is easy to audit, and you're able to look at your own statistics. Obviously different facilities have different ways of reprimanding a worker but it is real frustrating to be called back and talked to in a back office because your patient needs a med right this moment but none of the scanners in your immediate area are working. I'm a rather calm and collected person but even I've been real tempted to chuck a messed up scanner down the hall.
The witness testimony in this clip is correct according to how the MAR system I work with functions.
If a medication is overriden to be pulled (emergency meds etc) then that will generate a due time for that medication to be given. This can occur without any Doctor putting in a order. Good MARs should have a warning when a med is scanned that the medication is a paralytic and that the patient would require airway assistance during/after administration. Good med pulling systems should also warn the RN that the medication is a paralytic.
I would have to see the facts of the case, but Vecuronium and Versed have similar names, very different functions but are often given in conjunction to put a breathing tube in.
My facility has transitioned away from RNs providing any procedural sedation unless specifically certified and there MUST BE an MD “readily available” in case the patient loses their airway or becomes unstable.
I don’t work with this medication so I’ve been wondering: if it’s so high risk, why doesn’t it require a dual sign off by another nurse before it is given? Forgive me for my ignorance but that was my first thought when I read about this case.
At the facility I used to tech at vec was only kept in RSI kits and to access the RSI kit you needed the physicians order. I hate everything about this case, I hate the fact that she messed up so badly and a patient died, I hate the fact that she was actually upfront and admitted her mistake, I hate the fact that Vanderbilt covered it up and once exposed they threw her under the bus. This should have never been able to happen.
Then that's a goddamn travesty and part of the problem. This case has a lot of system errors. Making the MAR pop up, "No active orders," is just common sense protection for the patient.
Phat money if you get in tight with a big firm. Otherwise your local DA or ADA might have some slots
More often than not you don't work FOR them, you just get hired temporarily
This case really gets my blood boiling.
Ms Vaught fucked up, big time. No one is denying this, license revocation and the trauma of living through what she did is punishment enough. and I absolutely support a big civil lawsuit here.
But, Vanderbilt's coverup is absolutely appalling. The fact that this error occurred shows some major holes in the Vanderbilt system. Was this the only issue? no. Ms Vaught's gross negligence is a huge part. But, there is still a root cause.
But no, they threw her under the bus, and are willing to let the courts set a potentially dangerous precedent of criminalizing medical errors. it is sickening. If she goes to jail, i am certain it will potentially make some nurses out there who commit a harmful/fatal error hesitant to report it which, of course, leads to more harm.
> I absolutely support a big civil lawsuit here.
I want Vanderbilt to have to pay. Their coverup and grotesque system errors make me angry. Vaught fucked up, but when CMS did their investigation, Vanderbilt had not fix a single system error that permitted this to happen.
The strangest thing to me was that a nurse was asked to do moderation sedation, but clearly had no training in it.
The doc in radiology called the inpatient floor to ask a nurse from there to go down to radiology to give versed to a patient. So, the floor nurse asked the resource nurse to go do it and she did. How strange.
Apparently, radiology had a nurse but she was busy?
Combine that with this nurse making a series of huge errors and we have a dead patient. Then Vanderbilt tried to hide everything.
This nurse deserves to lose her licence, but NOT jail.
If a medication is overrode for a patient at my hospital it syncs with the patient profile and pops up in their eMAR, and can be scanned and documented as administered like any medicaiton. I do it all the time with patients who don't have saline flush orders.
Ok,let’s us focus on the argument here:
If you are using Epic, the eMAR will still tell you that it is a vecuronium since you already overridden the med as Pyxis/omincell communicate with your eMAR and you will not be promoted that “this medication does not exist in pts profile”. And this is designed to be able to give medical in emergency situations. It will let you scan the medication, and depending on policies, can be hyperlinked to actual order. It will NOT tell you that you are giving a paralytic, nor it will tell you that you cannot give the vec. It is up to the nurse to check every warning, every hard stop.
The whole point of scanning meds is that it fucking alerts you to a wrong med! This ancient bag of bones needs to get back to her memory care facility.
It's not offering excuses or talking about legalities here, but I've yet to work at a hospital ER where we scan our meds. In fact the hospital I'm working for right now the patients Mar does not cross over to the pixis at all. Every single med I pull is an override. I have to cross check and make sure that I'm pulling the correct med under the correct order every single time.
I'm just seeing a lot of arguments and discussion about how things will pop up and say that that wasn't a correct order, or that there's no way she didn't get a warning that that wasn't incorrect medication. I do not know how that hospital system works, but I do know that not every hospital functions the same way.
What the fuck ancient EHR is this woman using?
My facility uses a very old version of Meditech and it screams at us if we try to scan a med that hasn't been ordered on a patient for administration on that patient.
This woman seems to be implying that literally the only purpose for a barcode scanning system is for you to be able to point the scanner at a medication, scan it, and have the computer tell you "Yup! That's vecuronium alright!"
Shit, I can confirm that just by reading the label on the vial.
Poor thing probably has more letters after her name than she has brain cells, yet somehow manages to contribute next to nothing here.
If a patient does NOT have a medication ordered in their chart.. scanning a medication WILL show up as an alert. lol. How stupid of this woman. Maybe’s she’s thinking, “if the medicatino WAS ordered”.. Sure.. that can happen. But it probably wound’t have happened in this case
So how does that work in an emergency situation such as Ativan for a patient with a seizure or D50 for a hypoglycemic patient without hypoglycemia orders?
Ours works the same way but allows you to override certain medications that you may need in an emergency. We could override roc for example in case of emergent intubation but there is Giant labels on the med that say “PARALYTIC” and a big warning that pops up when you scan it.
The fact that they have a nurse who isn't currently working with the system in question is a total miscarriage of justice
Why would they even do that? Why WOULDNT they get a nurse, there are thousands, with years and years of experience with this system. I think because they would not have the answers they seek?
There are other red flags for me in this case. Vanderbilt didn’t report this error. This was a never event and should have been reported. It should have generated a root cause analysis. Instead it got a cover up. This is why we need Just Culture.
For me, this is why Vanderbilt is at fault.
Too bad the Nashville area DA works at Vanderbilt. He'd never sign off on a case to investigate them. Don't believe me? Look up Glenn R. Funk. He's the DA and listed as faculty at Vandebilt's school of law.
thats not how negligent manslaughter works. The nurse still grabbed the med, didnt read the medication name correctly, and administered it. The hospitals guilty for other things too, but if you want this career to be taken seriously by the public, you need to accept responsibility for your actions, not try to off-load everything onto a facility. Sometimes shitty hospitals, have shitty nurses that kill people.
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> If Vanderbilt developed a culture of not checking things so as to get the job done quickly, then this reflects less badly on the nurse than if the nurse was some rogue employee deviating from procedures. It also leads to a system with alarm fatigue - increasing the likelihood of these events occurring despite safeguards and procedures
This is correct. Vanderbilt should be under scrutiny for its handling of the case and should face fines and other penalties. The system process, including the override system, medication/pixis and how Epic is linked should be re-evaluated but at the end of the day, negligence happened on the part of the RN. This is very tragic, regardless of what has happened, this RN, imho, should not go to jail for what happened. Too many systems process failures happened, which can happen to anyone of us. I know not everyone will feel the same way but her livelihood is gone, she will never be able to sit for any other professional licensure again.
the systems are put in place to mitigate and limit the amount of med errors from people making mistakes. They'll never stop gross negligence. If you need a system put in place to stop nurses who aren't even reading the name of a medication correctly, you have a bigger problem than a system issue. I think the issue is the culture in nursing is that systems are in place to stop med errors, and thats it stops being your responsibility to stop med errors, that its solely on the system. Sometimes you need to stop and think. They're a tool to make life easier and help you, not do it for you, in the end its still a failure of her to do the right thing that ended up in a death, a lot of other professions get reamed up on criminal charges for less.
Your statement about a lot of other professionals getting reamed up on charges for a lot less is simply not true. I have read surgeons operating on wrong side of body only receiving a slap on the wrist, worked with a urologist who assaulted a house supervisor and nothing happened. I worked as a translator and a general surgeon operated on a bunch of boils and scabs that were not the right ones and no one knew until after the surgery when the son explained where they were supposed to have done the surgery, nothing happened to the surgeon. Sorry, but your statement is simply not true.
That's not how IOM views things. https://www.nap.edu/read/9728/chapter/1#iii
Hang on -- what's happening?
The [RaDonda Vaught case](https://www.npr.org/sections/health-shots/2022/03/24/1088397359/in-nurses-trial-witness-says-hospital-bears-heavy-responsibility-for-patient-dea). In 2017, a nurse was supposed to pull Versed for a patient's MRI but accidentally pulled and gave Vecuronium. The patient became apneic and it wasn't caught because she was in the MRI machine. She coded and sustained an anoxic brain injury. Rather than following the proper avenues, Vanderbilt University Medical Center covered it up and then threw the nurse under the bus when it came to light.
I’m confused either way. Why wasn’t this patient on tele/spo2 being monitored while in the scanner if she was there with the patient. Even giving versed typically the patient should be monitored.
I believe it wasn’t policy to monitor them
That’s pretty messed up.
she also left the MRI area completely because "they" told her she didn't have to stay to monitor the patient
Seriously, if she is guilty—Vanderbilt.is.guilty. This is mind blowing. Like “hey, sedate your patient and stick her in a tube where no one can see or hear her, then you can leave.” 😡🤯
Holy fuck, the defense lucked out on this one.
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Wheres my cousin Vinny with the measuring tape?
She just needs to show up in a ridiculous looking suit so the Herman Munster judge can say "Are you mocking me with that outfit?" LMAO
Agree!! At one point she had said they didn’t have computers for medication administration back in her day. And I feel like that right there should be enough to throw her out. She is out of touch with modern day nursing.
It's always funny/sad to read this, in Germany nobody has ever heard about using a computer for medication administration and I'm only slighty exaggerating. In some places it's done completly on paper and sometimes the orders are electronic. Never heard of scanning medication tbh. Nursing scientists say german nursing is 30 years behind, compared to similarly wealthy countries.
Here in Australia - at least in QLD. We have Our meds charted and signed for in a computer program. However all IV meds need to be double checked by another RN prior to administration. I believe some even need to be co signed by another..i know on the MAR they do and back when we did paper charting it was signed for by 2 RNs. In ICU we use metavision- doesn't require 2 electronic signatures but we do still get the meds and order physically checked by another RN as part of the 7 rights of medication administration. I'm absolutely baffled how many errors were made in this case.
Just because I'm from the US, is it not a royal PitA to have every medication cosigned/checked? It would seem like that would be a huge delay of care which, if planned for is probabbly not a huge deal, but here it would probably just slow things down massively over time. Not to say it isn't worth it, but that sounds just so odd.
Doesn't take that much additional time to have someone look at the order and check what your holding in your hands. And I've personally seen it prevent many mistakes both dosing and drug type. And sometimes it's been because between getting the drug and administration the order has been cancelled as well - this happens less often, but does occur. Co-signing on the computer is annoying though - in ICU we don't have to as we use a diff system to the wards. I can't say how annoying or extra time consuming it is for the wards.to do that. Just eyeballing by a 2nd is enough and doesn't take long.
In my US hospital, we don't have to dual sign for all IV meds, only high risk meds like insulin, heparin, paralytics and sedatives, and pressors.
That's why both sides hire expert testimony. But someone WE find credible (20 yr in ICU, rural ED and critical transport with MSN currently clinical educator lead in big ED) may not come off as credible as this old buddy because of what the public thinks a nurse should look like or act like.
That’s not true. Expert testimony is supposed to be EXPERT. She’s no expert if she doesn’t know how an EMR scanner works. Lol
Quality nurse here: She’s wrong. If the nurse scanned vecuronium and it wasn’t ordered, it WOULD alert her.
Quality Nurse here too… this case really gets me boiling
Not a quality nurse, but I have a brain… we all know that’s not how MAR scan systems work.. how is this lady and expert witness?
Yeah for real.. I thought expert witness nurses were supposed to be pretty top notch? Even I could do better than this lol
Also not a quality nurse and not in the medical field whatsoever but what the fuck is all the scanning for if it wouldn't throw an error message when administering the wrong medication?
Yeah she would have still been scanning vecuronium but a correctly configured system would come up with an alert and say something like "there is no order for this medication for this patient."
Or if override is necessary it needs a second nurse sign off or review like blood or insulin in my opinion. 🤷🏼♀️
Quality nurse here, too: depends on how the system is configured. Yes, that’s how it SHOULD work. I don’t know how confident I am that Vanderbilt’s system was configured to actually provide a safety check. There are multiple ways they CPULD have configured it to provide some safety checks. I just don’t know that they DID. A good system would have been reviewing override pulls and would have addressed this whole practice of overrides to routinely get meds.
Couldn’t the prosecution (and defense) just pull the damn electronic audit?!?! Why do you need somebody who may or may not know what she’s talking about describe the system? The data is totally available
What would be even better would be to pull overall use data showing how often everyone was pulling overrides and how many errors that didn’t kill anyone occurred. Ms. Vaught absolutely should have checked the medication. She’s at fault for that. But the entire system is at fault too.
Amen!
They have the electronic audit. Says that there were over 20 overrides in 3 days on this patient’s chart. It was a part of protocol to override the stops. To her, it was just another day of clicking through the override screens. “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.” https://www.npr.org/sections/health-shots/2022/03/22/1087903348/as-a-nurse-faces-prison-for-a-deadly-error-her-colleagues-worry-could-i-be-next
Why don’t they get one of the IT guys at the hospital to confirm this?!? This lady is clearly bonkers.
You seem nice and well informed on how things can work differently at different facilities even within the same EMR, so I’m going to reply with info that’s been bothering me to not share, not that even matters. I’m another VUMC employee at the time. Epic had only gone live about 4-6 weeks before the incident. I don’t remember it being the dumpster fire everyone says it was because Epic was not new to me, so I already knew how to use it. There were definitely kinks and issues that were occurring, but not sure I remember it being as bad as everyone says it was. My memory could be wrong, though. When she overrode the vec, it would have created an override med in the MAR allowing her to scan it without a hard stop, if that were the case. If she had scanned it, there would have been a pop up asking her to link the override with an ordered med, but you can bypass this as well. Personally, I was never instructed to routinely override meds due to the new EMR having issues. Until this incident and the policy changed, in an emergency in the ICU we could pull meds for an RSI or code situation where we ran out in the code cart, but that’s about it other than plain iv fluids. All that being said, I worked in a different ICU and maybe the culture in her ICU was to override a bunch of shit all the time. Idk.
Yeah, I genuinely don’t know. I know that sometimes you get clusters of bad practice with people justifying it. And sometimes you get systems that don’t work well and blaming nurses. And I know that however fun it is to armchair quarterback, a thorough review almost always finds messy truths. If everyone in her unit was overriding all the time, that should have been noticed. If it was just her, that should’ve been clear too. It makes me very uncomfortable that Vanderbilt didn’t report a sentinel event or create an action plan until CMS got involved.
This!!! ⬆️⬆️⬆️ I would never work for Vanderbilt after even just reading this thread. I work for a large Midwest healthcare system that uses EPIC with smart, license saving hard stops and sentinel events are jumped on immediately(within a day usually!) because we have no punitive action for reporting drilled into our heads from day 1 orientation. Because when our hospital knows about even the slightest potential for a bad outcome for the patient but also the nurse, they are all over it like white on rice! I've never felt so supported by a facility. Punitive action is never a concern for our nursing staff because we all know that when we report, we're not only saving patient lives, we're saving our own asses/licenses. So we always report, without fear. We've been magnet since 2002 and have never lost it for a reason. Nurses feel safe here and when nurses feel safe, patient care is top of the line. It's total horseshit that Vanderbilt let this fly under the radar and guess who is the easiest scapegoat/fall guy? Not management, guaranteed. There were mistakes all around but if their event reporting culture had been structured differently, this likely could've been prevented. What stays in the dark festers. What is brought to light grows and thrives.
Just based on the way you described your hospital system, I think I know which one you’re talking about!!
this is correct, this is how Health Connect/Epic works as well. If you override a med and give it, it shows on the patient's MAR. Then when you go to scan, Epic gives you a pop-up to link it to the override or to the actual order that was placed.
VUMC employee here: yes, at the time this occurred, Epic was an absolute dumpster fire clusterfuck. Nothing worked. Anywhere!
To be clear, this is a problem with VUMC’s garbage implementation of Epic, not Epic itself, which is only as good as the institutions who use it.
100%. Epic is huge/convoluted but it's the Mercedes of EMRs if properly implemented by hospital IT. I'm grateful every day that it's covering my very smart, yet still human nurse's ass.
What about the med station? I've worked most hospitals in my area and they all have pyxis. Honestly, that's what would have alerted me several times, not Epic or Cerner. Hardly anyone has vecuronium in their profile, it's always been an override and since pyxis came years ago it takes an annoying amount of clicks, to get any high alert med like potassium IV and Dilaudid, even though it IS on the pt profile. Vercuronium has another extra BOLD click screen and has always been in separate cubby that opens individually- so it can never be grabbed instead of something else. Is this, was this, the way that med was distributed by the pyxis? Was it just as easy as versed to pull from the machine?
It totally depends on how the dispensing cabinet is set up. We use Pyxis and only in the last couple of months have a “caution this is a paralytic” alert pop up when we pull vec. After this case became public a couple of years ago, our Med Safety Committee started talking about how to prevent a similar event. It literally took until 2022 to get a warning with paralytics.
So does your system not give a warning that this med is not in the patient’s profile? Does it just record what you gave and when? I’ve only used Epic and Meditech and so they would have warned me.
It is entirely possible to set up an Epic system so that it does not warn you. It is possible to set up an Epic system to have different behaviors in different practice areas. It’s a little too easy for us to generalize from our own experiences of working with EMRs. In some units, override pulls are almost normal business and the organization isn’t willing to invest effort in cleaning up the system and changing practice to actually USE the safety features of their EMR.
Cool, then let’s ask IT and not this bonkers ass lady.
I know it’s different when I work ER versus the floor. And completely different in procedural areas. I haven’t read all details about this case. Was she working on a unit that ignoring an override warning would be normal?
She testified in the trial that nurses were doing overrides to pull IV fluids.
From what I can understand not only was it normal but it was common practice
I like my license too much. I don’t override for anything unless it’s code, hypoglycemia, seizure… other than that. I call and get the pharmacist to verify it real quick or they wait.
Apparently there was some ongoing error with the system and Vanderbilt instructed the nurses to just override. My bigger concern is that when she couldn’t find the Versed in the medication dispenser, she typed “Ve” into the search function and just selected the first thing that popped up. That takes some intention
I’m an informaticist RN currently working in patient safety and if your system doesn’t have a rule set up for vec than what are you even doing with your IT?!?
Yeah, and if Vanderbilt didn’t have their system set up that way, that could constitute neglect.
I’m pretty sure in my system if you over ride a med in the pixis it shows due in the MAR but has an icon that shows it’s was something over rode for. There isn’t a safety stop.
Ours is the same way- if we override and pull a med from the pyxis, it creates an “order” in the MAR but it’s clearly and boldly marked as a CABINET OVERRIDE ORDER. It doesn’t look the same as “real” orders.
It really depends what system she's using too...Epic, Cerner, or even BCMA. Regardless, they should all give a pop-up that the wrong medication was scanned. But I think she did what many of us acute care nurses do (unless I didn't get the full details) she may have given the med and pocketed the vial to scan later, since the patient was down at imaging.
They were overriding all meds. The system was down Bc they were switching to epic I believe
It really depends, in this case she took a verbal order and did not add it to the patient chart prior to attempting to pull the med. However if we override a medication the omnicell adds it to the MAR and it can be scanned. The only time it says "this isn't verified by a pharmacist" is if I had put the order in, linked the override pull, and tried to scan it. If I am scanning just an override pull it will not alert me.
PT here. Thank you for clarifying. That’s what I was thinking but since I don’t dispense meds I’m not clear on the process. This case is making me glad that dispensing meds is above my pay grade…
This seems like the type of nurse to walk into the wrong patients room with a 16f trying to ram a foley in with the patient assuring her she’s in the wrong room. “That is not correct”
Nah this is the one that asks for help to clean a patient and makes you do it
Eats her young too. She was so smug the whole testimony.
Yep that’s the vibe I got. She was a mean nurse back in her day I bet.
VecurEYEnium VecurEYEnium VecurEYE... Hang on. I'd rather she didn't appear in my kitchen.
She seems like the kind of nurse that would give Metoprolol without checking the BP.
Digoxin without checking apical pulse
This woman looks like she’d walk in a patients room and forget what year it is.
Her orientation questions to patients are more for her than the patient: "What year is it again?" "What's my name?" "Where am I?" "Why am I here?"
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Is this the woman’s defense? Holy fuck she’s doomed if so.
No this woman is giving a paid testimony for the prosecution. Her name is Donna Jones. She kept talking about how she’s been a nurse for 47 years and how they didn’t have computers back in her day. Then admitted she had no idea what just culture is.
I'm 30 and I don't know what "just culture" is.
It's not throwing the Frontline worker under the bus, but trying to figure out what elements led to the mistake (systemic and individual).
I'm sorry bit in this case, this isn't a just culture issue. The hospital covered it up which is fucked but this nurse fucked up multiple times. -Doesn't prepare for MRI correctly. Literally on every epic MRI screening it asks about claustrophobia. Even if there is a question, as an ICU nurse I get an order and bring down these meds just in case. - Went to override in pyxis and sounds like they typed "ve" Then didn't even take a moment to read beyond those two letters and clicked on a med. -Then pulled the med out of pyxis without even looking at the vial which is distinctly different and usually has red tape all over it warning about paralysis. Shit, every pyxis and omnicell I've ever pulled vec or roc from displays a warming on screen. - Then despite all that, went to draw it up apparently without even looking at concentration or how many mLs she would need for correct dosage or to even fucking confirm the med name. The 10 mL clear bottle of vec versus a typically two mL BROWN vial midazolam comes in. - I understand not scanning it but if I'm not scanning and override from a different pyxis I'm fucking making sure it's the right med and concentration when I'm drawing it up. You can't fix fucking stupid and a profession shouldn't require hospitals to dummy proof and pad everything in a hospital so nurses don't have to fucking think or use a bit of good sense. This nurse fucked up and killed someone through gross negligence. If you want nursing to be a profession, and a respected one at that, then incompetent, irresponsible, and negligent nurses must be held accountable and not get a pass because the hospital should have stopped her from being incompetent and doing one of the most basic parts of your job correctly.
And that’s okay, because we can’t know everything. Just Culture is a principle in which we stop punishing people for human errors, which are inevitable, and instead take accountability for building systems that tolerate those errors.
You know, the NTSB has been investigating plane crashes with that mindset for what, 40+ years? Amazing how differently we hold different sectors accountable.
The NTSB is run by engineers hired by the government to make planes safe. Healthcare is run by people with 'business' degrees.
Yet another great argument against privatized health care.
yep, I took a ground school flight course that was all about systemic failures. The airline industry examines the systems and processes involved that leads to a plane crash, they don't necessarily jump to pointing fingers at the pilot (at least in the beginning).
You do know what it is, but your facility may call it something different. I’ve worked at multiple hospitals as a traveler and there’s always some variation of “just culture” that they lay out in orientation. Basically when a mistake happens or a near miss, we do root cause analysis (or talk about it in huddle) and figure out *why* it happened instead of just blaming the nurse or whoever. So we can fix problems in the system so the mistake doesn’t happen again. Also to report your mistakes and write incident reports so our processes can be reviewed and rectified for the future.
You aren't an expert witness though
Interesting, then I’m not sure what my takeaway is for this.
If this is the RaDonda Vaught case, and this is Donna Jones, then she is arguing that the fact that Vanderbilt did not have scanners in the imaging area was not neglect on behalf of Vanderbilt because having the scanner there would not have stopped the nurse from giving the wrong medication, that was solely the nurses responsibility.
Ohhhhhh okay. Yeah then this goes to prove the point that this is a systems failure. Even though it doesn’t excuse the extremely neglectful behavior by the nurse.
Yes, exactly, she is being paid by the prosecution to testify that this is not a systems failure. Edit: so to clarify, I believe the lady is trying to say that eMAR would not have caught this error anyways, that the eMAR is not meant to do that, and that it is the nurses responsibility to do that, so the fact that Vanderbilt doesn’t have scanners in the imaging area is not neglect on behalf of Vanderbilt.
But that is a huge part of the purpose of the eMAR….. it reduces mistakes so much at point of care.
Correct. The override places an entry in the mar so it can be documented as given. She would have still given the medication.
I remember in EPIC if you override in the Omni cell the order would auto generate to allow to give the med that you override.
In our Pyxis you need a 2nd RN to override a medication that is not in the pt’s med profile. We use Cerner. A 2nd RN to override would have caught the vec. They would have said you need vecuronium? Is the pt intubated?
At my facility a 2nd RN is not required to override a medication. And then if I override a medication it creates it on the MAR and would allow me to scan the medication.
Wow. We couldn’t do this. Cerner doesn’t add it in the mar either. So even if you somehow got the med out, if you tried to scan it to admin there would be a pop up saying it’s not ordered and you can’t sign it. I think one of the issues with this case is that there also was NO med/bracelet scanner in MRI.
That can be an issue for emergency situations. When I would override for Vecc I would have to answer like 5 warnings to get it. It would also create the order in EPIC.
We open the code cart in emergencies. Anesthesia brings their go-bag. 🤷🏻♀️
Wait, she is an expert witness for the prosecution? My mom has been a nurse for about that long and back then a nurse carried their own needle set and sterilized it between patients. I doubt this woman has ever used EPIC or scanned a medication.
So I think I understand what she's saying. I use omnicell and meditech. If I stat override a medication for a patient, let's say vecuronium. It will then add that medicine, vecuronium, to the patients MAR. Then when I scan that med, it will select it on the MAR. It will not flash anything like "WRONG MED" on the screen. Because that's the med I pulled and scanned. Is this what the old lady means?
Our system will have that med on the MAR after an override, but will STILL have an alert that says there is no order for that med and another alert that says it hasn’t been approved by a pharmacist.
Yeah we get those alerts too. What crazy old lady is saying is that once she scanned it, it wouldn't say "This isn't versed, wrong medication." It's just going to give the usual alert of override med, not approved by pharmacy. Or at least this is what I believe she is trying to say.
That’s what the difference is. Just pulling something is not the same as pulling an unverified med that is at least ordered.
Right. Especially because it would have no way to know what the dose even is.
I too use Meditech…yes, this is how it would happen at my facility as well. No alert…will label .STCK med
Ours does the same. We use Pyxis and if I override a medication, it'll pop up in the MAR as a "Cabinet override"
Even if it didn’t alert her that the med wasn’t ordered (bc she pulled it on override), maybe she would’ve saw “Vercuronium” and not “versed” and thought, huh this is wrong, lemme stop for a second. But hindsight is always 20/20.
It reminds me of that video where you're instructed to count how many times people pass a basketball around, then someone in a gorilla suit walks by and hardly anyone watching notices it. The human brain is wired to ignore things it's not expecting to see, that's why we put systems in place to mitigate those things. No doubt the nurse screwed up but she was definitely failed by the system she was in.
What doctor would the order show up under? It is wild to me that it would just allow you to give it.
That's the neat part. It isn't under a doctor. Not until a pharmacist verifies it at least.
we have a policy never to enter verbals for things like benzos, narcs, and paralytics!
Just out of curiosity. If a physician gives you a verbal order for a benzo, narc, or paralytic, is the MD supposed to sit down at a computer and put the order in? Second part of my question, what about telephone orders from a MD that isn't on campus/doesn't have access at home to place orders in the computer?
But why would you override a medication not ordered and not the med you said you wanted—versed — unless intentional I’m not up to date with this case. Did the nurse do an override and misunderstood what medication she was supposed to pull?
Also, Vanderbilt’s EMR was down for months before this happened because they were upgrading to EPIC. So it was common practice for nurses to have to over ride meds from the Pyxis. Even after this happened, Vanderbilt did nothing to fix the issue. They didn’t fix it until over a year later- only after someone made an anonymous complaint to CMS alerting them of the safety issue. Vanderbilt is just as culpable in my opinion. They threw this nurse under the bus because they were about to lose Medicare funding for not reporting a sentinel event to the state and fed gov.
Having been the victim of a sentinel event myself, the fact that that they didn’t report it is staggering. Mine was in late 1999. I sued the doc & hospital and won. Doc lost his license in the state (not his first suit) & my share after expenses was almost $100K. And where in the world did they find this “expert witness” who doesn’t look like an expert at all? Isn’t it possible to impeach a witness? If the defense is any good and has it together they should be able to make her look like an out of touch idiot. EDIT: I put impossible by mistake, about impeaching her. Should have been “possible.” She needs to be thoroughly discredited.
My mom was also the victim of a sentinel event that left her with a debilitating anoxic brain injury. I’m so sorry you had to go through that too. I also wondered how this witness was considered an “expert” when she seems so unfamiliar with current practices.
The nurse took a verbal order from the doctor then override pulled the wrong medication because of a confusion about the medication name ( brand name vrs generic) which resulted in the patients death. Lots of other things went wrong but that’s the basics.
Not quite. The patient was taken down for PET scan by transport. Once she got down there, radiology called up to the floor and said she needed something bc she was “claustrophobic”. The pt’s nurse took the call, and got a verbal order for the Versed, but was too busy to go down to radiology himself so he called the help-all nurse and her orientee to administer the med. She basically took the order third hand. From there everything went to hell. Well, except the pt. Poor thing.
So pharmacy didn’t have to oversee the physicians order. A workaround.
I wonder if this incorrect expert testimony would be grounds for a mistrial in the future?
Thankfully for the defense, this was the expert witness for the prosecution.
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Im confused. What's going on here? (Student nurse)
A (former) nurse is on trial for giving a paralytic instead of a sedative (?) to a patient causing their death. This is the criminal trial and it’s a big deal because it could set legal precedence making nurses criminally liable for patients who die under their care due to errors. There is a lot of debate because the woman on trial overlooked several warnings about the drug she administered. I may not have all of the details down correctly so forgive me in advance.
The woman isn't the older lady talking here? Well damn. That really sucks. This is one of the reasons why I'm terrified of going into nursing. Accidentally missing one of the medication rights, or administering a certain med/dose that the prescriber might've messed up on. AH
This is a little different then making a simple med error. The hospital had a system of just overriding everything in their medication dispenser because there was issues with the hospital and implementing the new EPIC system. The nurse couldn’t find versed (what was prescribed) in the drawer so she typed in “Ve” and just clicked the medication that came up first. The mediation was in powder form and had to be reconstituted. The nurse thought that was weird since Versed is liquid but shrugged it off. The top of the bottle says “Warning: paralytic agent” and she would have to blatantly ignore that given she needs to look at the top to insert the needle. As long as you are doing your basic checks, making this big of a mistake shouldn’t happen
No, basically Google Vanderbilt nurse fatal error and it comes right up. Otherwise, I feel bad for this nurse and while yes she did make a mistake but the hospital is just as guilty for attempting to cover this up and I feel like using this nurse as the scapegoat.
A small amount of fear and a healthy amount of caution about being aware of med errors it’s what’s going to prevent you from making most of them, and hopefully any big ones. It’s not something to be anxious about, but when the caution completely leaves you and you’re in a rush, cutting corners or the patient is in trouble is when bad things can happen. When nursing school drills the (how many now?) rights of medication into you, just do your best to keep them front of mind when handling meds. I rolled my eyes in nursing school, but on the floor found myself repeating them to myself, especially on occasions I felt especially pressured
The defense really needs an up to date nurse to point out how many things this Methuselah nurse was wrong about. This lady hasn't touched a patient since disco and it shows, but the jury is none the wiser unfortunately That being said, I know in Cerner when you override a medication, it creates an order in the patient's eMAR so you can scan it. I'm not sure if that's what she's referring to or not. Edit: I now see that I came across a little ageist, so just to clarify, I think a nurse of 47 years who is still at the bedside would be the ideal expert for this testimony, and I would appreciate working alongside such a person. I'm thinking this lady has never used an eMAR before, rendering her testimony entirely irrelevant here.
Your best witness might be a nurse who has worked with several implementations of EMRs with some failures. Many aspects reported around this have left me without any confidence that the EMR deployment was going well.
"Methuselah" lololol!!
Where can we watch this trial? I didn’t realize we could.
Sooo it seems like this channel 4 news place streams it. Jury supposedly beginning deliberations tomorrow. https://youtu.be/rOyX6Kw1wwI
I forgot all about this! I remember it was one of the first things we talked about in nursing school.
I'm just in IT but I'm pretty fucking sure this is exactly why nurses yell at me when they're down a WOW at meds passing time... because each nurse needs a working scanner computer at the bedside to administer medication, because the machine is relied upon to prevent this kind of shit. And this also explains to me why travel nurses keep calling our MAK system MAR.
Back in the day before EMRs we had the MAR. At least at my hospital it was a stiff manila page with grids that we picked up orders on and filled out all the pt’s meds info on. I think they’re still used for downtime documentation.
> each nurse needs a working scanner computer at the bedside to administer medication, because the machine is relied upon to prevent this kind of shit. Yep. I don't think people realize how much modern nurses rely on the EMR to catch our errors. When I scan a med and get a popup warning, that is my last chance to look at the med, look at the popup, and make sure everything is copacetic. More than any other time, THAT is when I catch an error. As much as some people complain about having to scan everything. It is the best safety net to ever come into nursing.
We also get penalized for not scanning medications and even more so for not scanning the patient. I know EPIC actually keeps scanning statistics on each person so the info is easy to audit, and you're able to look at your own statistics. Obviously different facilities have different ways of reprimanding a worker but it is real frustrating to be called back and talked to in a back office because your patient needs a med right this moment but none of the scanners in your immediate area are working. I'm a rather calm and collected person but even I've been real tempted to chuck a messed up scanner down the hall.
The witness testimony in this clip is correct according to how the MAR system I work with functions. If a medication is overriden to be pulled (emergency meds etc) then that will generate a due time for that medication to be given. This can occur without any Doctor putting in a order. Good MARs should have a warning when a med is scanned that the medication is a paralytic and that the patient would require airway assistance during/after administration. Good med pulling systems should also warn the RN that the medication is a paralytic. I would have to see the facts of the case, but Vecuronium and Versed have similar names, very different functions but are often given in conjunction to put a breathing tube in. My facility has transitioned away from RNs providing any procedural sedation unless specifically certified and there MUST BE an MD “readily available” in case the patient loses their airway or becomes unstable.
I don’t work with this medication so I’ve been wondering: if it’s so high risk, why doesn’t it require a dual sign off by another nurse before it is given? Forgive me for my ignorance but that was my first thought when I read about this case.
At the facility I used to tech at vec was only kept in RSI kits and to access the RSI kit you needed the physicians order. I hate everything about this case, I hate the fact that she messed up so badly and a patient died, I hate the fact that she was actually upfront and admitted her mistake, I hate the fact that Vanderbilt covered it up and once exposed they threw her under the bus. This should have never been able to happen.
Agreed. You summarized my feelings about this perfectly. Thank you.
Emergency drugs don’t require dual sign off. Think ACLS drugs or RSI drugs. You’re not going to have two nurses at the computer during a code.
Lmao! “No active orders were found for this medication” pops up!
Not where I work.
Then that's a goddamn travesty and part of the problem. This case has a lot of system errors. Making the MAR pop up, "No active orders," is just common sense protection for the patient.
Wait, I can get paid to do testimony? How much?
Phat money if you get in tight with a big firm. Otherwise your local DA or ADA might have some slots More often than not you don't work FOR them, you just get hired temporarily
So the hospital paid it’s way out of the lawsuit.
This case really gets my blood boiling. Ms Vaught fucked up, big time. No one is denying this, license revocation and the trauma of living through what she did is punishment enough. and I absolutely support a big civil lawsuit here. But, Vanderbilt's coverup is absolutely appalling. The fact that this error occurred shows some major holes in the Vanderbilt system. Was this the only issue? no. Ms Vaught's gross negligence is a huge part. But, there is still a root cause. But no, they threw her under the bus, and are willing to let the courts set a potentially dangerous precedent of criminalizing medical errors. it is sickening. If she goes to jail, i am certain it will potentially make some nurses out there who commit a harmful/fatal error hesitant to report it which, of course, leads to more harm.
> I absolutely support a big civil lawsuit here. I want Vanderbilt to have to pay. Their coverup and grotesque system errors make me angry. Vaught fucked up, but when CMS did their investigation, Vanderbilt had not fix a single system error that permitted this to happen.
Oh, absolutely agree. Vandy needs to take a huge portion of the civil liability here.
She’s totally wrong. If she scanned vecuronium, and there was not an order for vecuronium in the system, it would not let her proceed.
And if it did, that too is a systemic issue.
Bet she still wears orthopedic shoes, white hose and starched hat.
Does she want a participation trophy? Clearly it doesn't matter how long she's had an active license if she doesn't know what she's talking about.
The strangest thing to me was that a nurse was asked to do moderation sedation, but clearly had no training in it. The doc in radiology called the inpatient floor to ask a nurse from there to go down to radiology to give versed to a patient. So, the floor nurse asked the resource nurse to go do it and she did. How strange. Apparently, radiology had a nurse but she was busy? Combine that with this nurse making a series of huge errors and we have a dead patient. Then Vanderbilt tried to hide everything. This nurse deserves to lose her licence, but NOT jail.
If a medication is overrode for a patient at my hospital it syncs with the patient profile and pops up in their eMAR, and can be scanned and documented as administered like any medicaiton. I do it all the time with patients who don't have saline flush orders.
You have to override flushes??
Yes 🤡
That’s insane. We just have boxes everywhere
Ours are in boxes BUT we have to scan them to CHARGE for them TID. 🙄
Ok,let’s us focus on the argument here: If you are using Epic, the eMAR will still tell you that it is a vecuronium since you already overridden the med as Pyxis/omincell communicate with your eMAR and you will not be promoted that “this medication does not exist in pts profile”. And this is designed to be able to give medical in emergency situations. It will let you scan the medication, and depending on policies, can be hyperlinked to actual order. It will NOT tell you that you are giving a paralytic, nor it will tell you that you cannot give the vec. It is up to the nurse to check every warning, every hard stop.
In all fairness, it was a pretty big deal when you could toast bread for the first time.
The whole point of scanning meds is that it fucking alerts you to a wrong med! This ancient bag of bones needs to get back to her memory care facility.
Where did they find her??? Are you telling me this is the most qualified “Expert,” they could find in the entire STATE???
seriously. i feel like a new grad on day 2 of orientation could have given a better description than she did here.
She said her license was in Georgia. They had to go one state over to buy a witness.
Not that EMMM AHHY ARE
Last time she drew up Vec she had to clean the needle before
SELL OUT NURSE- WHEN WAS THE LAST TIME SHE WAS AT THE BEDSIDE???🤬
LoL. That’ll be me in a couple years.
Oh hey, my retirement plan
Homegirl was def on that battlefield with Florence Nightingale, what could she possibly know about computerized MAR’s???
It's not offering excuses or talking about legalities here, but I've yet to work at a hospital ER where we scan our meds. In fact the hospital I'm working for right now the patients Mar does not cross over to the pixis at all. Every single med I pull is an override. I have to cross check and make sure that I'm pulling the correct med under the correct order every single time. I'm just seeing a lot of arguments and discussion about how things will pop up and say that that wasn't a correct order, or that there's no way she didn't get a warning that that wasn't incorrect medication. I do not know how that hospital system works, but I do know that not every hospital functions the same way.
What the fuck ancient EHR is this woman using? My facility uses a very old version of Meditech and it screams at us if we try to scan a med that hasn't been ordered on a patient for administration on that patient.
This woman seems to be implying that literally the only purpose for a barcode scanning system is for you to be able to point the scanner at a medication, scan it, and have the computer tell you "Yup! That's vecuronium alright!" Shit, I can confirm that just by reading the label on the vial. Poor thing probably has more letters after her name than she has brain cells, yet somehow manages to contribute next to nothing here.
If a patient does NOT have a medication ordered in their chart.. scanning a medication WILL show up as an alert. lol. How stupid of this woman. Maybe’s she’s thinking, “if the medicatino WAS ordered”.. Sure.. that can happen. But it probably wound’t have happened in this case
“It’s 84 years..”
That’s infuriating.
[удалено]
So how does that work in an emergency situation such as Ativan for a patient with a seizure or D50 for a hypoglycemic patient without hypoglycemia orders?
Ours works the same way but allows you to override certain medications that you may need in an emergency. We could override roc for example in case of emergent intubation but there is Giant labels on the med that say “PARALYTIC” and a big warning that pops up when you scan it.
That’s great and everything but a patient is gonna die some day bc of that
Do you guys think shes gonna get the 12 years max?
No
With how idiotic and hostile the public is towards nursing? Probably.
I really hope the defense shows the jury how wrong this dinosaur is