Our hearts continue to go out to the loved ones of both Ms. Murphey and Nurse Vaught, all of whom are deeply affected by this tragedy and face a long road of healing. A lead investigator in the criminal case against former Tennessee nurse RaDonda Vaught testified Wednesday that state investigators found Vanderbilt University Medical Center had a "heavy. All rights reserved. In 2018, an anonymous tip sent to the Centers of Medicare and Medicaid Services about the incident prompted a hospitalwide investigation. That is how they nailed us in IT. The American Nurses Association, in conjunction with the Tennessee Nurses Association, offered the following: We are grateful to the judge for demonstrating leniency in the sentencing of Nurse Vaught. Its just that stopping and thinking about it isnt much fun. The RaDonda Vaught Case: Implications for Healthcare Providers But jail? I wrote down the license number and immediately went to the local police department and reported it. Required fields are marked *. Please try after some time. Criminal Conviction of RaDonda Vaught sets Dangerous Precedent in Vaught faced a potential sentence of up to eight years imprisonment. For a long time, most people were saying that most accidents were due to human error. And that really should have been the end of it. Pennsylvania Patient Safety Authority. Playground fires in Baltimore yield arson investigations, spark community concern. Structures should include full and confidential peer review processes to examine errors, deploy system improvements, and establish corrective action plans. Articles of interest on the case or about nurse malpractice: https://ajnoffthecharts.com/case-of-nurse-charged-with-homicide-for-medication-error-raises-concerns/, https://www.tennessean.com/story/money/2018/11/30/vanderbilt-patient-death-medication-error-medical-examiner/2155152002/, https://www.bigcountryhomepage.com/news/nashville-da-on-radonda-vaught-case-verdict-is-not-an-indictment-against-the-nursing-profession/, https://www.npr.org/sections/health-shots/2022/03/25/1088902487/former-nurse-found-guilty-in-accidental-injection-death-of-75-year-old-patient, https://www.usatoday.com/story/news/health/2021/07/23/ex-vanderbilt-nurse-radonda-vaught-loses-license-fatal-error/8069185002/, https://www.usatoday.com/story/news/health/2019/12/15/vanderbilt-vumc-radonda-vaught-medication-error-vecuronium-charlene-murphey/2454711001/?gnt-cfr=1. Yes, but your comment referred to just the article, and I found that the article was missing a lot. Vaught is quoted as saying that at the time of Murpheys death. RaDonda Vaught DA Discovery - DocumentCloud Although Vaught received probation, her criminal conviction and three-year sentence may lead clinicians to think twice about such open reporting of errors. Prosecutors agreed there was no evidence she intended to kill Murphey. She typed in "V-E" to the system and took out Vecuronium instead of Versed, ignoring warning messages and a large label on the medication vial reading "Warning: Paralyzing . The failure to monitor the patient was another safeguard bypassed there is always the potential for an idiosyncratic reaction, especially if the patient has never received this sedative before. Lost your password? J Clin Psychiatry. Mistakes are a tragic but inevitable aspect of medicine, because people are an essential part of medicine. Despite the pandemic, nurses still had their dividing lines: masking/no masking, vaccines/no vaccines, shutdown/life as normal, politics, unions/anti-union, abortion, euthanasia. Yeah, I get that, and also that we want no errors ever is about as feasible a proposition as we want no traffic fatalities ever. Did NASCAR pay enough to use Grant Park, downtown streets? RaDonda Vaught and nurse burnout: what really should be done. J Nurses Prof Dev. I can see numerous root causes here, starting with malfunctioning Pyxis. When we are bombarded with many warnings during a busy shift, from pop-ups on our computer screens to the bells and beeps emitted by the monitors, we become desensitized to them, an experience known as alert fatigue. RaDonda Vaught sentenced to three years' supervised probation. It is unbearable to think that if there had been a different outcome for the same action, this nurse could be banned from health care and imprisoned. This was achieved with the support of the Federal Aviation Administration, which worked with the industry to form a number of programs that monitor for and ensure compliance, like the Commercial Aviation Safety Team. Unfortunately, medical errors can and do happen, even among skilled, well-meaning, and vigilant nurses and health care professionals. Seems to me it should have included a lot more, without having to go to other referenced articles. Lessons Learned From the RaDonda Vaught Case Look up @ thenurseerica, look up @ sassynurse2021 for humor and just let the algorithm take you. The premise is focused on both detecting and responding to risks. Hank from the Internet (View Comment): This essay outlines nine steps that should be taken to maximize patient safety and minimize the risk of criminal prosecution for harm that results from human error. Nurses at all levels and across all settings provide care in demanding work environments with challenges that predate the COVID-19 pandemic. In the hours after the verdict, candidate Sara Beth Myers issued a statement calling Vaught's actions "civil medical malpractice" that should not have been handled in criminal court. Many health care workersparticularly nurseswork grueling hours while facing distractions, like alarm fatigue, that contribute to making errors. Chicago Park District boss defends agreement, Chicago police are investigating if cops had improper sexual contact with immigrants, including allegedly impregnated teen, Dear Abby: Woman doesnt know our father is also her father, Dozens of immigrants moved from police station where officers are being investigated for alleged sexual misconduct, Cubs Dansby Swanson withdraws from the All-Star Game, Daily Northwestern alleges explosive new hazing allegations tied to Pat Fitzgerald suspension, Cubs put Dansby Swanson on IL, recall Miles Mastrobuoni. Top Republicans are gearing up to investigate the Hunter Biden case. https://tdh.streamingvideo.tn.gov/Mediasite/Play/d4e0d6b971de40a7a361928 https://www.nursingworld.org/news/news-releases/2022-news-releases/state https://www.aacn.org/newsroom/aacns-statement-on-the-conviction-of-radon Kelman B. A number of them are wrongfully accused of negligence. I guess the next question along those lines is if Versed is always a liquid or sometimes a powder, but I think I really dont want to play prosecuting attorney here (or on TV). Any mistake can impact the lives that health care workers entered the profession to protect. As I wrote before, I think a good portion of the blame shifts to anyone who didnt monitor the patient once it was known that the wrong drug was given. Last month, a jury in Nashville found Vaught guilty of negligent homicide and gross neglect of an impaired adult. The PubMed wordmark and PubMed logo are registered trademarks of the U.S. Department of Health and Human Services (HHS). Michael Ramsay, MD, is the CEO at the Patient Safety Movement Foundation, a global nonprofit with a vision to eliminate preventable patient harm and death across the globe by 2030. Bethesda, MD 20894, Web Policies When major medical errors occur, accredited third-party organizations like The Joint Commission, the Centers for Medicare & Medicaid Services, or the Agency for Healthcare Research and Quality should routinely conduct independent investigations. AACN's Statement on the Sentencing of RaDonda Vaught She went into the medication-dispensing machine and attempted to type in the brand name of the medicine. In fact, unless safe patient ratios are established, they could be the next headline nurse in handcuffs. Please try again soon. The criminal conviction and sentencing of a nurse for a medication error is a backward step for patient safety. Criminalization of Human Error and a Guilty Verdict: A Travesty of Warning fatigue now a matter of criminal liability: the RaDonda Vaught Story. The patient's family called comments by some candidate candidates "humiliating" and "degrading," and says the ongoing national debate over the case has "retraumatized" her family, according to a statement released by District Attorney Glenn Funk's office. RaDonda Vaught case: where do things stand? - American Nurse Journal Overriding the dispensing machines routinely instead of in emergent situations due to frequent malfunctions, thereby negating a critical safety measure meant to ensure administration of the proper medication to the correct patient, No patient scanner in the PET scan room to verify specific patient drug dosages, An order from the staff nurse stating, No need to monitor the patient, Vaught being pulled away from her primary task of treating a patient in the emergency room when the call to administer the drug was made, The request for patient sedation from a technician in the lab rather than a clinician. This article was published more than1 year ago. In a well-designed plant, a simple error like closing the wrong valve shouldnt result in an accident. I mean a lot, including the report from CMS. It is entirely possible that the medication was not the sole cause of death, although it is probable. The RaDonda Vaught Case: A Critical Conversation on Nursing Practice and Technology AACN Adv Crit Care. I urge them to let leadership know when they cannot safely complete all the expected care within a shift. Vaught offered to run down to the scanner to administer the medication to the patient. Tennessee Department of Health. [1] She was sentenced to three years' probation. Supporters for Vaught have rallied on social media platforms like Twitter and TikTok, while a petition circulating online calling for clemency has already gained more than 200,000 signatures. During the course of her employment at VUMC, Vaught made . On May 13, 2022, RaDonda Vaught was sentenced to three years supervised probation with judicial diversion. I think is will answer some of your questions. Journal for Nurses in Professional Development, Get new journal Tables of Contents sent right to your email inbox, November/December 2022 - Volume 38 - Issue 6, A Call to Action Following the RaDonda Vaught Case: A Culture of Safety and High-Reliability Organizations, Articles in PubMed by Mary A. Dolansky, PhD, RN, FAAN, Articles in Google Scholar by Mary A. Dolansky, PhD, RN, FAAN, Other articles in this journal by Mary A. Dolansky, PhD, RN, FAAN, Best Fit Orientation: An Innovative Strategy to Onboard Newly Licensed Nurses, Measuring Return on Investment for Professional Development Activities: Literature Update and the Ongoing Challenge, A New Era for Nursing Education: Implications for Practice. Its a sad story and, yes, the criminal prosecution seems extreme. Here is a summary of coverage from professional organizations, news outlets, and other opinions and reactions since the original verdict on March 25: Former Vanderbilt University Medical Center nurse RaDonda Vaught is being charged with reckless homicide and abuse of an impaired adult after mistakenly administering the wrong medication that killed an elderly patient in 2017. April 1, 2022 By Kati Kleber, MSN RN 20 Comments The RaDonda Vaught trial has been a major issue for the nursing community. Reconsidering the application of systems thinking in healthcare: the RaDonda Vaught case. Radonda Vaught never tried to hide her medication error. They are applying it to the larger context of the current climate of nursing, including the ever-growing nursing shortage. It is argued that the prosecution of Ms. Vaught was wrong; however, in contrast to some commentators, it is argued that the wrongness of Ms. Vaught's prosecution did not stem from its effects on patient safety, but from the fact that the charges, in this case, were legally and ethically unjustified in themselves. This has been called the second victim effect of medical errors. Yeah. A Call to Action Following the RaDonda Vaught Case: A Culture of Safety and High-Reliability Organizations. Vaught, 36, of Bethpage, has been criminally indicted on abuse and reckless homicide charges after she allegedly gave a patient the wrong medication, leading to her death. On March 25, 2022, most of the healthcare community were shocked and dismayed after learning that RaDonda Vaught had been convicted of criminally negligent homicide and gross neglect of an impaired adult following the 2017 death of Charlene Murphey. RaDonda Vaught 38, was found guilty Friday of two charges, criminally negligent homicide and abuse of an impaired adult, for her failure to catch the mistake at several points before Murphey was injected. Then came the harassment, They locked their 8-year-old boy in a dark room for months. As the investigation continued, she worked construction jobs. Cynthia A. Oster, PhD, MBA, APRN, ACNS-BC, CNS-BC, ANP, FAAN, is Patient Safety Nurse Scientist, Emory Healthcare, and Adjunct Assistant Professor, Nell Hodgson School of Nursing, Emory University, Atlanta, Georgia. Those using her death for personal gain should be ashamed.". The recent case of RaDonda Vaught, the Tennessee nurse who was found guilty of negligent homicide after accidentally administering the wrong medication to a patient who subsequently died, has nurses and nursing students rethinking if this profession is worth their own personal risk. A Call to Action Following the RaDonda Vaught Case - LWW Accessed September 1, 2022. So something isnt adding up. MeSH The Code of Ethics for Nurses states that while ensuring that nurses are held accountable for individual practice, errors should be corrected or remediated, and disciplinary action taken only if warranted. Kill enough people under a large enough title and it no longer becomes criminal, apparently. Smith pointed out thatVaught was transparent in reporting the error; she showed remorse; her mistake was unintentional; the incident was not done in malice; and she had no intent to do harm.
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