She pulled the wrong med, and then injected it and walked out of the room rather than observing for effects. Also the med she pulled had warnings on all sides of the bottle and on the top saying very clearly that it's fatal to administer without ventilation. This went beyond a mistake to negligence.
“In response to a story like this one, there are two kinds of nurses,” Garner said. “You have the nurses who assume they would never make a mistake like that, and usually it’s because they don’t realize they could. And the second kind are the ones who know this could happen, any day, no matter how careful they are. This could be me. I could be RaDonda.”
https://khn.org/news/article/radonda-vaught-nurse-error-medi...
HN readers can look at this case filing:
https://www.documentcloud.org/documents/6785652-RaDonda-Vaug...
> Also the med she pulled had warnings on all sides of the bottle and on the top saying very clearly that it's fatal to administer without ventilation.
The linked PDF includes images of medicine in question. There's a single warning on top that reads "WARNING: PARALYZING AGENT" and a red cap. I don't see any warnings on the side. The vial appears to be tiny, smaller than my thumb.
But yes, she made a series of mistakes, listed on the last two pages of the PDF.
I am not a nurse, but I can easily imagine how someone could make the errors she did in an overworked and high-stress environment. It's a cascading series of errors that starts with overriding the medicine cabinet when she can't find the medicine she's looking for. But according to her defense, overriding the cabinet had become almost standard operating procedure at Vanderbilt at that timeframe. Once she starts down this path, she's operating on automatic and almost blind to what she's doing.
I agree she was negligent. I don't think she should go to prison for it. In the bigger picture, this is causing more nurses to quit, likely leading to more medical errors and deaths, not fewer.
There are so, so many differences between the two meds, I don't see how confusing them would be possible short of gross negligence (for context, I am a paramedic, and often administer medications (including both of the meds involved here) in a high stress environment).
Vecuronium (the paralyzing drug) is a powder in the vial and you need to first inject saline it into the vial, shake it up, and then draw out the "reconstituted" med. This is very unusual (there are only a handful of medications in common use that require this, and Midazolam, the intended med, is _definitely_ not one of them). The reconstitution process means she would have had to look at the top of the vial several times, and warning on the tops of vials are, again, very uncommon. Also uncommon is the red cap on the vial.
I have made errors before while caring for patients, and I will likely make them again. I am very aware of the fact that we all can make mistakes, but the number of mistakes that needed to be made here far exceeds the standard of what is reasonable, and is well into the territory of "gross negligence", in my opinion.
But let me allow for a second that this is a case of gross negligence, despite the fact that CMS investigated Vanderbilt and found many other issues in the workplace:
https://www.documentcloud.org/documents/6535181-Vanderbilt-C...
It's not clear to me how criminalizing her mistake helps prevent future medical errors. Do you think criminally prosecuting her was the right decision?
but we literally have a law for "negligent homicide"?
Her employer, by not creating a culture of safety, set her up for failure.
I just don't see how in the long term this prosecution reduces medical errors and generally disagree with criminalizing mistakes; even ones such as this.
edit: minor grammar fix
With staff shortages nurses dont have the time for that.
Hire 2x more nurses - so there is 2x more time for each patient.
No, very different from every other med in the drawer. The red cap on the vial is very unusual (reserved for very dangerous meds like this), and the bold printed warning on the top (that you have to look at at least twice while while preparing to administer this medication) is also something used very rarely.
The hospital has far too many incentives to play fast and loose and then leave the nurses in the lurch with a system stacked against them. The hospital has far too many incentives to skimp on training and safety. etc.
Should this nurse also have her license looked into? Yeah, it looks like it. And is it up to the hospital to fire her or not? Yes.
However, barring actual proof of premeditation, all charges and fines should land on the hospital--not the nurse.
Edit: I should say that doesn’t mean I think it makes any sense the hospital isn’t liable and jail time for the nurse seems odd
