RaDonda Vaught was staffed as a resource nurse at Vanderbilt. This apparently is a “help-all” type of position. She had two years experience as a nurse at that point.
She was asked to give a dose of Versed to a claustrophobic patient who was being downgraded from ICU to stepdown, was getting an MRI on the way to the stepdown. She had to give the medicine and then go on immediately to a different task. She also had a trainee with her.
Again, this is a nurse with two years experience, being the “help-all” for multiple floors AND training a new hire.
She had to override to get out Versed. This is because, at that point in time at Vanderbilt, most or all meds had to be overridden. The patient she was giving the med to had already had 20 other meds overridden to give to her.
She inadvertently got out vecuronium instead. (It's entirely possible that a nurse of two years who isn't in someplace like ICU has never actually given either of those meds.)
She wasn't able to scan the medication either, because there was no scanner available in the MRI department.
She gave the patient the medication, and then had to go to another part of the hospital directly after. Then the patient coded at some point during MRI, and died.
Sure, she made plenty of mistakes. But I think it makes more sense to punish Vanderbilt in some way for putting her in such a risky situation. This was bound to happen sometime, and the powers-that-be were 100% aware of that, and chose to roll the dice on it anyway. It just so happens that this patient and this nurse were the ones who had to suffer for it.
Vanderbilt needs to take responsibility for:
- Allowing guardrails like profile medications and med scanners to be broken/unusable, and stay that way indefinitely.
- Staffing a person in a role they don't have the experience for (and having them train others at the same time.)
This stuff is going to happen more and more often. Hospitals are allowing travelers to be charge nurses, or nurses with <1 year. They know this raises the risk of basically every adverse event, but it makes the profit margin better than paying for experience does.
Same with the med safeguards and scanners not working properly. In my facility, about 20% of the meds won't scan even if it's the right med. Because they switched makers or something and it never gets updated in our EMR. And about half the computers for scanning are broken or so old and slow that it takes 10 minutes to document a Tylenol. I am acutely aware that it makes it that much easier to make mistakes and I don't think a mistake that precipitates from facility issues should result in a criminal conviction for the nurse. If a med scanner, or a Versed profile order was in place that day, this mistake never would have happened.
Source: the above message was posted as a comment for an “explain like I’m 5 question” to the Radonda Vaught case. Credits to @captain_gadeon for the excellent summary.
I work in corporate compliance and I 100% agree with the above sentiments. This case honestly underlines how far executives will go to indemnify themselves. It’s one thing to get your license suspended or revoked for a medical error on the job, it’s another to hold someone accountable criminally. She is facing years and years in prison. I’m honestly in disbelief.