Is Nurse Who Caused Excruciating Death of a Patient a Victim? | RaDonda Vaught Case Analysis 

I am a nurse and I am kind of confused why a paralyzing agent would be in a Pyxis machine in the first place. This type of med is used for intubation and regular staff nurses don’t do that procedure. If the hospital would have kept these meds locked away and only certain staff would have access to it, then this never would have happened. The hospital and medical examiner should also be prosecuted because they both covered up the error which is negligence on their part. Since the hospital has all the money and they never seem to punish doctors when they make mistakes, the nurse ends up taking the fall for the entire incident. And I heard that she was helping out another nurse when this error happened, maybe if hospitals and nursing homes had safe nurse to patient ratios, med errors would be reduced and lives would be saved. Just my thoughts.

There are some serious problems in our healthcare system. While Redonda made a series of grave errors, the hospitals actions afterward are reprehensible and almost guarantees this will happen again. I want to see them punished but feel it is unlikely.

I'm a nurse. This case disturbs me, makes me think. Cases like this can make me consider my own practice in a critical fashion. The idea of "missing something" has always given me pause, and I'm sure it makes other healthcare workers think twice and thrice. Maybe that's the only good part of cases like this - if you let them, they can make health care workers examine themselves, and perhaps avoid future mistakes. When I heard of this case, my first thought was, didn't Radonda monitor the patient's reaction to the drug after she gave it? Couldn't she tell the patient's vital signs indicated increasing distress? Versed's not something you administer, then walk away for half an hour. You monitor the patient, for God's sake. Sedated people are extremely vulnerable. Hard to say how and why the patient went unmonitored. Bad practice? Distraction? Overwork? Complacency? I suspect there's more to the story. Vanderbilt Hospital's hiding what happened doesn't surprise me one bit. It's partly an outcome of the idea that a hospital should be run on a "business model" (@@) rather than as a health care center. There's also this myth that healthcare can "take care of its own" including its own bad actors. In my opinion, it cannot police itself, at least not entirely. I'm sad for the patient and for her family. The patient's death must have been awful. I'm conflicted about Radonda. Usually when big medical mistakes happen, they don't happen in a vacuum. They are an outgrowth of a wilderness of error, combined perhaps with increased-on-chronic personal stress. The stakes are high in healthcare. It's extremely important for healthcare workers to be in environments that monitor for distracted, overwhelmed workers and that honestly encourage telling the truth about mistakes.

This is a lesson to know and practice our five rights every time! Right patient right drug right dose right route right time.

I think you left some parts out. #1 Radanda was a new nurse of only 2 years yet was already training another new nurse.#2 The area where the medication was given did not have a scanner#3 It was not hospital policy to stay with a patient who had been given a medication like the one ordered. #4 She didn't leave the patient alone, she left the patient with the technicians, and they told her it was fine. #5 The dose she gave may not have even been lethal, and due to the cover up by the hospital no autopsy was done. They tried to prove she gave more than she admitted to by using evidence that the hospital (the hospital that lied continually) had kept for a year before authorities took it into their possession. Anything could have been done to the evidence during that time.

her employer is as guilty as she is. I'm a pharmacy technician, if we override the computer it has to be double checked and signed by another employee, any non-compliance would be flagged in a monthly audit.. seems that nobody was taking responsibility (including her)to protect the hospital, the employees or the patients. It's very scary that some institutions run with such a disregard for basic safety guidelines.. I don't understand how they legally maintain a license

The thing that upsets me is that while the nurse is facing prosecution, Vanderbilt who is also responsible is essentially getting off scott-free. Our justice system needs better ways of punishing companies that behave badly.

A nurse saved my life by questioning a doctors order. Thanks to her I am alive and well today.

I’ll accept the necessity of criminal prosecution of the medical community when criminal prosecution is just as eager and capable of convicting Vanderbilt as it is to prosecute Radonda Vaught. My fear is nurses will become scapegoats for hospital corporations.

I’m a nurse. A lot of drugs are similar in name. They teach you the five rights. Right patient, right drug, right dose, right route, right time. There are many factors that contributed to this error, but it does come down to actually reading the drug name and identifying the patient old school style.

This makes me wonder how many other patients she was careless with

As a retired registered nurse that witnessed many EGREGIOUS nursing errors, my experience was that the medical institution covered up these errors EVERY SINGLE TIME. It was despicable.

The 3 checks: 1.) Check the medication with the patient's record 2.) After preparing the medication 3.) At the bedside after identifying the Pt using 2 identifiers The 6 rights to medication administration: 1.) Right Patient 2.) Right medication 3.) Right dose 4.) Right route 5.) Right time 6.) Right reason - being consistent using the 3 checks and 6 rights saves you from this nightmare

I have lived in Tennessee, and I would rather operate on myself, than to ever seek medical care there again.

As an anesthetist it disturbs me that anyone without anesthesia training would even have access to Vec or any other paralytic for that matter. It should NEVER happen for any reason. They aren’t taught the uses and dangers of these drugs and therefore shouldn’t be able to touch them.

As a nurse it's unfortunate the hospital didn't also face legal responsibility. I understand she made multiple mistakes however the hospital walked away Scott free. Edit: reaching a settlement with the family isn't justice

So sick of big organizations covering up crimes. We teach and expect _kids_ to take responsibility for _their_ mistakes, accidental or purposeful, but adults go and do the opposite. You said precisely what I would have said about this situation. I wish I could give you a great big hug for understanding how I feel! Love you, Dr. G! 🤗

Excellent analysis. As a non-medical person, I've worked in the medical community for a few years. Cover-Up , is a big thing. It's disgusting and criminal.

Taking the erroneous medication out of a "Documed" type of dispenser is one thing. Initially I had fortified the nurse, but as the facts kept emerging, it got worse. One of the cardinal rules of administering any medication as a nurse is the "Five Rights" or the "5 R's"l 1. Right Drug 2. Right Dose 3. Right Time 4. Right Route of administering 5. Right Patient She mentally conceived she was giving Versed, she should've checked those rights twice, let alone giving Vercuronium. It's not rocket science that you should follow these guidelines. Every instinct in her should have ceased her. However, the cover-up Vanderbilt orchestrated and executed, is nothing short of horrible. From the CEO down, they all should be held accountable for being an appendage. The family being able to be bought off for their muteness is revolting and Vanderbilt is a Despicable hospital.

Absolutely good analysis. I'd also love to see the hospital get charged for the negligent cover up.

As a retired ICU RN for 40 years - I can tell you that the paralytic administered to her rendered her helpless to move anything, including her diaphragm, and she had full consciousness through most of the time it took her to smother. Question - video says she was a "licensed " nurse. Is this an LPN or an RN? There is a big difference in responsibilities. Absolutely NO LPN should be allowed to give Versed.

This is the best explanation of this case that I have heard. I was surprised when I watched the trial that the victim’s DIL said the family didn’t want the ex-nurse prosecuted. Truthfully I wouldn’t have been that forgiving. I’d want the public (possible future patients) to be aware of what happened.

I'm not in the medical field, but I heard the drug she used is usually locked up and the packaging has extra color so it can stand out that it's stronger than most. She sounds like a sloppy nurse. You listed a lot of other ways she was negligent. If you aren't capable of paying attention to details, please stay out of the medical field. I feel for the victim and her family. It was a senseless death 😢

I was a nurse for 35 years. Police and nurses should not be protected from criminal prosecution. The majority would never have made those mistakes. Having the power of life and death over others carries a heavy burden. If the consequences of your actions is more than you can shoulder then choose another way to make a buck!

Had this happen to a family member. Over dose of heparin. The nurse denied the mistake and I went ballistic and to the top of the food chain in that place. Already in a very compromised health situation, this would had been lethal for this person had I not been there. Don't be afraid to ask what it is and how much. It might jog someone's mind and avoid a mistake.

Why is the nurse the only one being held accountable? The hospital and its’ systems failed her and the patient. Redonda immediately reported what happened. Then the hospital covered it up. Who is acting criminally here?

I think Radonda needs to take responsibility for this, she said it herself. However, I disagree with your somewhat cynical take on the nursing profession that hospital mismanagement makes them feel at liberty to not pay attention. In my experience, nurses are much more worried they will take the fall for doctors and administrators' mistakes, rather than the other way round. For example, it is common for on call night shift doctors nearing the end of their hours to put off care so that days shift will have to deal with a given problem and they won't have to come in the middle of the night. If something happens as a consequence of this, it's more likely to be pinned on nurse complacency or miscommunication than physician irresponsibility. Things like that happen all the time. Most hospitals are understaffed and nurses are often expected to take unsafe patient loads, pick up mandatory overtime hours, and work in environments where cost cutting and mismanagement make it difficult to operate safely. This is far from the only hospital overseen by the type of corrupt individuals who tried to cover this whole thing up. Rather than complacency, the nurses I interact with go to sleep terrified that tomorrow is going to be the day when, overstretched and exhausted, they make a mistake such as this. Ultimately, Rodonda made a terrible mistake which she must live with, but it's plausible to say that her managers created an environment where mistakes were much more likely. It's a crappy situation, no doubt. It's also crappy that the corrupt admins who did illegal things (like ask nurses to override safety protocols in the medication cabinets and hide negligence from the police) seem to be facing no responsibility outside earning a bad reputation. Correct me if I'm wrong. Radonda needs to take responsibility, but more investigation is needed.

Of course she should have been charged. Like bad drivers that don't pay attention, are reckless etc, kill people on the roads. Imagine a delivery driver saying "but I didn't intentionally kill that pedestrian" - well, that's nice, but you shouldn't have ran the stop sign, while looking at your phone and driving on the wrong side of the road. It's not the same as if you're doing everything right and somebody jumps in front of your van and you run over them and kill them. It does matter if you intended to do something or not, but that doesn't mean you're now suddenly not responsible for your actions. You still messed up, you're still guilty of causing death to someone, who is innocent in that scenario. You have certain responsibility, you can't just say - "oh, stuff happens, nevermind. Now get off my back, otherwise other professional drivers will be afraid to drive their vehicles, because if they kill someone unintentionally, they might be prosecuted too".

I work at a med/mal law office. Medical "mistakes" happen much more than you would expect.

Dr Grande, I cannot express my gratitude for your videos. I’m in hospital for a month. My chemo isn’t working, so I’m getting a bone marrow transplant. And I have to stay here for at least a month. That prevents me from getting sicker when I’m in an isolation room. So I’m not exposed to any germs. I was just crying so hard. Then I saw u just posted. I know I sound lame, but the humor u have also helps boost moral. Thank goodness that my medical service dog is staying here in my room with me. It’s helped me so much. And my daughter comes 3 times a day to take Jake outside to potty. She also brings me things I need. I feel so blessed to have Jake. And your humor also cheers me. I would have fallen off the deep end if not for Jake and RU-vid. This is the lowest time in my life. To add to things, my grand daughter was born with DIPG. She passed away 2 weeks ago. Then my daughter took her own life cuz she lost her daughter. Every small thing means so much to me. Right now I’ve lost all hope. I also feel that we shouldn’t ever ever waste time at all. Missing opportunities to spend time with loved ones, well it only leads to guilt. I would do anything to spend one more minute with my loved ones. So I’m working on not losing any opportunities to spend time with loved ones. Because that alone makes me feel so useless. That’s why I’m so grateful for videos and time I can spend with the family I have left. To I thank u so much. It’s a lonely life. And to add to this story, I worked as a RN and then BSN at Vanderbilt. I also knew this nurse. The best way is to say she is an EX nurse. She seriously was very strange. I’ll tell u more if anyone wants to know. It was so clear that she wasn’t right upstairs. I feel that she needed a strong antipsychotic and to be locked up. She felt she was above the law.

Vandy patient here, and i have to agree Vandy is partly to blame. I was also given the wrong drug at Vandy... AFTER my bracelet was scanned and everything. There were definite procedural problems. I often feel a bit guilty for not sueing them when it happened to me.. but i felt SO sorry for the nurse and when the hospital administration met with me i was in a vulnerable state, and they may have taken advantage a bit. I felt guilty suing, but now guilty for not

I was an ICU nurse for most of my career and also did conscious sedation for a few years with the drug versed. I also administered paralytics and sedation while people were on the vent so I know any paralytic is brightly labeled with red labels and has multiple barriers to get into it. At the very least anytime you give an IV sedating drug you need to assess immediately for effect and come back within 10 - 15 minutes to reassess how the patient is doing. The effect of vecuronium is almost immediate and should have been noticed. Initially I was ambivalent about this when I caught the end of the trial and heard Ladonna speak to reporters but I hadn't known which drugs she mixed up. Now that I know more details I do think it's right but I don't know that eight years is appropriate. Med errors are most often caused by systemic failures but bad nurses can eff it up all on their own once in a while. The 2 neurosurgeons should also get a ding against their liscences for lying to the medical examiner. I hope JCAHO cited the hospital also.

The patient should not have been left alone for thirty minutes whether she was given Versed, or any other medication of this nature. She could have been put on Oxygen and been put on a vent temporarily. All the other mistakes that were made were very much negligent in safe nursing administration of meds. I am an RN and have given Versed many times.

Excellent analysis. She should not be exempt. It’s too bad that the laws don’t apply to law enforcement.

I was so hoping you would cover this!!❤️ I have worked with other nurses who have done this type of thing before!! I can understand once, but this was her second time doing this. She was fired from her previous job for the same exact thing and she had only been a nurse for two years. She’s not the only one a fault here either!

She was honest and upfront about the situation. The hospital swept it under the rug. If she's criminally culpable, then the others involved with the cover up should be prosecuted as well. We're constantly short staffed at the bedside and asked to do the impossible with limited resources. This is a complex issue that doesn't deserve one person being scapegoated like this. Sauce: I'm an RN, practicing for 6 years in the acute care setting.

Yeah, Vaught lost me when she didn't scan the medication and patient's bracelet barcode. It's mandatory to use the bedside medication verification specifically to avoid situations just like this.

I am a retired RN and I am appalled at how many times this nurse had an opportunity to rectify her original error and she did not! This is more than sloppy, it is criminal.

I am an RN. The "system errors" that were in place before this nurse pushed the med are glaring. This is a sad day as med errors will now go underground and will never be resolved. So sad that it's, "Always blame the nurse."

That nurse just made too many mistakes. Agreed, at some point the negligence just becomes so gross/reckless that it does rise to the level of a criminal offense. Especially if it causes the painful death of a vulnerable, elderly patient. The hospital also should have had better oversight and safeguards in place.

This is the most objective analysis I've seen regarding this case.

Sad,this happens much more often than we can imagine

I’m an ICU Nurse, 24 years. This case: disturbing on a lot of levels. Her mistake was bizarre when you compare the two medications. Most people in my business call Versed midazolam. We don’t use brand names. Typically a Pyxis or Omnicell won’t deliver Versed. If you keep pushing the letters VE, the Pyxis says ok, you keep asking for Ve, I will give you VEC. In addition, if all these hospitals keep trying to do more with less, this is what you get. COVID just put the shortages under the microscope. I will say, this mistake…. Unacceptable.

Finally some accountability in the medical community

When I first heard of this case I did not realize how many of the safety factors she ignored! The truth is nurses override the medication dispenser all the time, especially in critical care areas where you need to have access to drugs the pharmacy has not yet released to the patient profile. I could see how in a hurry she would pull the wrong medication but there are so many red flags past that point that she ignored! The fact that she had to reconstitute that drug is a biggie not to mention not scanning the patient's arm band! There have been times when I have pulled the wrong IV solution or medication and the armband saved me! At the very least that patient should've been on a portable monitor when in the CT scanner! What a terrifying way to die! You are right… Hospitals do hide mistakes! I think criminal prosecution is a good thing!

My gosh, all I can think of is how much this poor elderly woman suffered! I watched the interview with this nurse, I didn't see any remorse, nothing. I'm glad you covered this one Dr. Grande 😊

Dr Grande, I love this analysis. I would compare a nurse who kills someone with a medication error, and no follow up, to a peace officer/police officer who accidentally shoots someone. Yes accidents happen, but there are accidents, and ACCIDENTS, which could basically be prevented, with a slow down and think moment. When you choose a career, making yourself responsible for other people's lives, you are then responsible. Thank you again for these great analyses. Love from (the still snowy) Canada 🇨🇦

I’m a nurse and I agree with the charges. There were too many safe guards in place that she completely neglected and then didn’t even monitor her patient afterwards is unacceptable as a nurse. Her main job is to monitor change and she failed on everything in this situation.

Professional organizations always want to police themselves. And when they mess up. In their mind the ultimate punishment that could ever be handed down is the loss of a license. When you're in the business of holding other people lives in your hand. The ultimate punishment should be criminal prosecution. How many times have you heard police departments repeat the narrative. Just need more or better training? Every incompetent action is blamed on training or procedure. Not personal responsibility.

What a tragic and horrible death, and after listening to your video- what a inexcusable amount of mistakes that were made! I so agree with your comment "The RaDonda Vaught case is not a good example of a case that should have been ignored by prosecutors." Also really loved your final thoughts, Dr. Grande!

You are the best commentator on line. Your voice is so expressive and measured, very easy on the nerves no matter how horrible the case. You also have a delightful dry sense of humor. Please keep on commenting on the cases that no one else can make sense of. I am a fan!

Surely being called RaDonda was an important causal factor...

Looking forward to hearing your thoughts on this topic, keep hearing about it nonstop. Thank you, Dr. Grande! 💜

As a Registered Nurse who has been in this business since 1987, I can tell that you have no idea about conditions in hospitals nor the extreme pressure that nurses are under. I am not defending this nurse’s actions whatsoever. I would like to see a video from you showing the dangerous understaffing of hospitals all over this country. Apparently, the general public has been kept painfully unaware of the national nurse shortage and the dangers associated with the shortage.

Why can't we just have this guy as a jury in all US court cases? Good job man 👏 👏

Dr. Grande, thank you so very much for taking my request! I truly appreciate, and can’t wait to hear what you have to say about this case. Thank you!💕

It is interesting to note that she always admitted making the mistake.

It's unfortunate but doctors/hospitals often bury their mistakes. We put healthcare professionals on such a high pedestal that we often have blinders on and don't do our due diligence researching doctors, surgeons, hospitals...If this patient had no family this likely would have been brushed under the rug. I do have respect for healthcare workers and doctors and realize they can often save lives and help improve our quality of life. However they are human, make mistakes, can be impacted by stress and some are more skilled than others.

If she had administered a non lethal drug by mistake--no harm no foul. Same mistake but no repercussions. . What is to be gained by putting her in prison--she no longer has a nursing license so she is no danger to the public.. This is a bad precedent--it's the rare doctor, paramedic, EMT or nurse that on a busy, stressful shift has not made a mistake. Do they all need to purchase individual malpractice insurance and drive the cost of health care even higher. I posit that if the hospital and nursing board had done their job-i.e immediate investigation and disciplinary action, including revoking her license, the person who likely felt like RaDonda got away with this mistake and turned her in, would have felt like something had been done and wouldn't have taken that step. Happens all the time.

Brilliant analysis Dr. Grande! Thank you for sharing your thoughts on this particular case!

I have some thoughts on this. First I would say that what is good for the Goose is good for the Gander. I have personally seen things that Doctors have done that ruined a patient's life but lawyers say that it is impossible to sue the bar is too high. Another thing is that not all organizations cover this type of thing up but they are Very willing to throw the nurse under the bus when there are many flaws in the way they operate which led to the mistakes. Number one is insufficient staffing compared to the patient load.

Vanderbilt hospital shares the responsibility of what happened to this patient. First they were having problems with the mechanism, second why was vecuronium put in with Versed? Vecuronium is clearly an anesthetic agent. No anesthetic agent should be put in a cabinet with Versed especially right next to Versed.

The suffering the *real* victim went through, slowly dying in that manner, is horrific.

It only takes a second or two to double-check that you have the correct medication. She was grossly negligent in what she did. My mom was a head nurse for twenty years, so I am familiar with proper procedures. She should have read the vial out loud to herself, and again when telling the patient what its name is and what it's for.

"Do your job well no matter what. Doing it poorly will not make you like it better." And you could possibly cause the death of your customer.

I admire how you articulate the facts and explain the terms in an organized concise manner in simple terms and of course with that bit of sarcasm to lighten things up. I also appreciate how you share your thought analysis at the end to provide moral perspective. Your platform is a great service to many in understanding “the system” and human nature. You’re right this was a very sad case of lacking principles and accountability for the nurse and organization

Dear Dr. Grande, I hope that one day you will analyze the case of a Greek mother, Roula Pispirigou, who is currently facing charges for the murder of her 9 year old daughter, and very soon two other charges will be added for the murders of her two younger children. This whole case is extremely disturbing and it is assumed that the motive is her jealousy and an attempt to keep her husband from leaving her.

I'm in the nursing field and I was just made aware of this case a couple of weeks ago... but, yeah, trading versed for vecuronium is a sentinel event: one which results in grievous harm or death due to neglect of safety protocols, it's sobering, but we exercise the 5 rights of med administration for a reason (right patient, right medication, right dose, right route, right time)... adhering to these would've prevented this...

I read a lot of comments. I’m not in the medical field, but I am convinced this was a case of gross negligence!! Plain and simple.

I have watched med errors happen at a hospital. None that were fatal but , it does happen. When it did, the nurse reported it: the hospital l had a meeting and created new measures to check the medications between the doctors, pharmacy and nursing : and then trained all the nurses on this potential error so that it won’t happen again. That is how mistakes should be managed: review the issue, find out what caused it, prevent it from happening again. Not ignore it. Not brush it under the rug. Because ALL of us will be in a hospital bed someday and we have to know we are safe.

Doctors are given far more professional leverage in “negligence” situations. They get a pay to play via insurance payouts when they fuck up. This is a labor inequality issue.

I’m a little halfway through your book Harm Reduction and i am hooked! 😃You’re really good at True Crime/Fiction writing!

I'd like to know how many times she had administered Versed before this incident and what was she doing instead of monitoring the patient.

It is clear the nurse’s organization, and others opposed to this prosecution, are concerned that criminal charges in cases such as these will place those in the medical community on the proverbial “slippery slope.” The facts of this particular case are so egregious and indicate a such a gross deviation from the standard of care as to justify the charges and the outcome. It is up to all of us to insure that the justice system reserves such action only for incidents of this magnitude.

Thank you for this video. I hope it reaches at least a fraction of the nursing community who have embraced this nurse and defended her gross negligence . I am, of course, deeply disturbed at this nurse's obvious gross incompetence and being portrayed subsequently as a " victim" herself-- a portrayal which she seemingly accepted. I am deeply concerned with her apparent lack of genuine acceptance of her responsibility in the suffering and death of this patient. In my opinion, the prosecution and conviction of this now- ex nurse was just, fair, and necessary. The attitude of a substantial number of nurses regarding this case- as demonstrated via social media-- is disheartening to me. Some demonstrate such a low level of basic reasoning in excusing her actions as " an honest mistake" ( whatever that is), that one should wonder how they themselves are functioning. They cannot see that-- obviously-- " the healthcare system" indeed, cannot police itself. Then there is the morality of the collective nursing community. The arguments made in support of this nurse include this perhaps pathological belief that she has been made a scapegoat of a massive corporate healthcare system. While Vanderbilt Hospital did indeed have some obvious flaws and willfully engaged in a scheme of deception after- the-fact, no hospital administrator took a paralytic out of an automatic medication dispensing machine, ignored the warning, reconstituted a drug (that any neurological ICU nurse would know did not require reconstitution) etc. No administrator injected this medication. No administrator failed to observe Mrs. Murphy for the effect of what was believed to be a sedative. Only this nurse could be held accountable and responsible for these actions. Further, many nurses claim that this case will cause nurses to not report their errors. So, what these nurses are stating is that nurses will lie about their medication errors? ( Actually, many already do). That belief demonstrates a rationalization for and acceptance of a reduced standard of care in an occupation that is already compromised by fast-tracked nursing education and the recent depiction of nurses as "heroes"--- which many seem to have taken to heart. Good nurses who care about the standards of care-- those whom you want at the bedside-- will see the benefits of the outcome of this case. Those who histrionically claim it will cause a mass exodus from the occupation-- perhaps should consider leaving as well. In my own careers as an ICU and ER nurse, an ARNP, a nursing instructor, an expert witness-- I have learned that the closing of ranks by nurses to protect one of their colleagues is a sign of a flawed collective conscience, if you will. I can only hope that the relatively small number of nurses who justly and accurately comprehend the magnitude of this nurse's negligence will ultimately influence their less aware colleagues.

This is the best discussion of this situation I've heard. Another great video, Dr. Grande!

You’re the only “true crime” guy I can really watch! I enjoy learning about people and why they do the things they do, and you’re able to provide the facts without making things extra “spooky”.

i'm a nurse and i do sympathize with her and the situation with the hospital system. but this is precisely why we cannot rely on technology to do our 3 med checks. i wish the situation was different all around though.

Dr. Grande, I can trust you to be objective and to let no-one off the hook. Two things I appreciate, very much. Thank you.

As a registered nurse, I can tell you that you are taught in nursing school from day one to READ the medication label SEVERAL TIMES before administering any drug. You also have to monitor the patient. She should lose her license at the very least. The hospital needs to be punished for their part. With that said, nurses are often given dangerous patient loads that will cause more errors and neglect. I have no idea if that was also a factor, but this nurse was acting in a dangerous manner.

When I first heard you talk about this, I was thinking that, yes, the nurse made an error however she did go to the hospital administration and admit her mistakes and that, imo, it was the hospital staff who were "criminal" in their intent and behavior, not the nurse. To some extend, in the process of reporting I still believe that to be true. The nurse did not attempt to hide her "mistake". Boy, at the end, when you hear the series of "mistakes" you realize there comes a point where it is no longer a mistakes, but rather just gross incompetence! There should be a requirement that it takes 2 people to override the safety measures in place. This just should never have happened, but to make things even worse, imo, is the behavior in hiding the truth from authorities, and their responsibility to report these things. It was the hospitals decision to lies and cover up (criminal imo) the truth of this whole thing. If she hadn't have left her alone, and seen the patient couldn't breath, could the patient have been saves? Could she have been put on a respirator? Did the patient have to die? This is all horribly inexcusable, and hope that the decision makers in this case are also brought to justice. Seems anymore in business, if profit is the end game, it appears to be acceptable to lies, and expected in most cases. Look at our own political leaders of our country. They outright lie with impunity all the time. It makes me sick.

Dr Grande, could you please analyze Edgar Cayce? He was a healing psychic with seemingly uncanny ability.

Your silly jokes and offhanded one liners are so hilarious! ( My poor cat though.. He is so sick of being startled by unexpected guffaws, and mommy jumping up to rewind!) Happy Sunday, everyone!

I am a registered nurse, and while it's inevitable to make some medication errors during a career, this particular set of events is horrifying. most people outside of the hospital don't know that the number of medication errors nurses CATCH on doctors' orders is astonishing, and no one is talking about this. we find an error, call the doctor, and give him/her the opportunity to self correct. the nursing board should have taken away her license from the start, but criminal charges?? if we go down this rabbit hole, nurses may not self report medication errors, which makes everyone much less safe.

There's a saying that my dad used to use when speaking of doctors: he would say "not all doctors were "A" students in med school". He was, of course, pointing out the incompetence of some in that profession. I believe it applies here also.

After seeing the warning on the lid which said Warning a paralyzing drug. It was not mislabeled and she left her 30 minutes when she died. Because the wristband and the drug had a check and balance and should have clued her in to her mistake. I agree with the prosecution.

I think it’s very telling that action only started when the public became aware action from CMS- action from the hospital- action from Board of Nursing. It’s disturbing that these things occur in healthcare and are not followed up on. What usually happens is these nurses will just building jump. Huge difference between mistakes and outright negligence.

I just retired as an RN of 45 years. By the Grace of God I never made a mistake like this but,all I can think is: That could of been me. Anyone being so pious is just wrong. There were so many holes in this system that, unfortunately, it made for a perfect storm. Nurses need to unite, not divide. The hospital is the one that should be on trial here. It failed to report the error which opens up for chances of possible increased errors. An out of court settlement with a gag order was made. Now, for some odd reason, it’s brought out again into open and I feel it’s the hospital trying to cover up. Administration knows of RN’s being understaffed yet do nothing about it and know we won’t walk out on patients or an assignment . I was taught NOT to let patients know we are understaffed. We were made martyrs.Why did the hospital not have patient/med scanners? It’s about doing the most with bare minimum. The hospitals will work the medical staff to the brink of collapsing while administration is on holiday in Figi.

This is very sad, my condolences go out to the family of the deceased. 💐

There’s a lot of people who haven’t worked in a hospital in here and it shows. There are some major systemic problems that contributed to this error that are completely being ignored in favor for blaming one person. Why was this med in the same machine that served the PET? It’s not exactly a med that is administered often there and it should not have even been there. Why was there no second nurse override? Most hospitals have a two nurse override and no permissions for a nurse to blind open a full drawer. Why isn’t the hospital system being held responsible for their part of the coverup, which the nurse didn’t actually participate in. Why wasn’t the patient monitored? Was it a drop off or was a tech supposed to have been there as well, what were the protocols and how were they not followed. Did she not scan because she chose not to or because she wasn’t able to? (I am actually not sure about this answer.) Yes. She made a med error. She made the steps that created the situation. However, that’s ignoring the fact that she should not have been able to make many of those mistakes.

Great video, Dr Grande! I was running my usual back and forth monologue out loud as it played. I felt bad for the patient, then the nurse, and even the hospital, a little bit. By the time it was over, I only felt bad for the poor patient. That nurse just plain violated to many rules to ignore. Another informative, evenhanded take, doctor. Thank you.

Finally, I hear someone speak some sense! I've seen so many nurses on social media stick up for the woman and it terrifies me! One mistake fine I can understand, but she multiple serious errors. My father fell at home and was taken to the hospital. Someone messed up his medication at the hospital. He had to be resuscitated and was in the ICU on an intubation ventilator for a few months. We didn't know why he was in the ICU for a fall until he was released from the hospital and the family doctor told us what had happened (apparently it's the procedure?). It's been about 5 years now and he is still in a wheelchair because he never was able to walk again. Dangerous people shouldn't be around vulnerable people.

Can you do an analysis on what would possibly cause parents to name their child something like RaDonda?

Are the doctors who lied about the cause of death being charged?

Dr.Grande the paralyzing agent should never have been in a dispensing system. That was the biggest error.. This agent should have been locked up in a different cabinet because this agent only belongs in the operating room.!!!!!!!!! It should never have been there especially if there are meds that sound alike. So thats why all the safety mechanisms didnt work. In our hospital these kinds of meds are never in the dispensing system and cannot be administered by an RN no matter what unless a doctor is present and there is a second nurse verifying the med. So the hospital was guilty because it did not prevent a nurse that was "out of it" to make this horrifying mistake. The med should NEVER have been available to her.Yes she is guilty of simply not reading the name of the med. We have been taught to RELY on these dispensing machines. As an older RN we were taught to read the name of med on the vial three times especially a drug like this. All around not enough checks to prevent this deadly error. All RNS make mistakes due to the fast pace , the patients screaming for pain med. At this point you have to take a breath and STOP, Read the name, verify it then proceed.This mistake could have happened to anyone.Look up the case of the twins that were given a very high dose of heparin and how all of that went down. It happens to a Hollywood actor. The babies did survive.

Thank you so much. I feel like this is one of your most important videos. Thank you for covering this case and the issues behind the case.

I'm a nurse too, so watching this on the edge of my seat 😁

Nailed it! I could not agree more with you. I honestly could not think of someone who so deserve the place they created in this platform. Salute! 🙋

Nurses (good ones) in hospitals know more about their patients then the physicians. They spend more time with the patients. That said they need to be patient advocates and think about there patients well being at all times. This duty is become harder and harder with short staffing, more responsibilities and floating to unfamiliar floors with little or no training.

Frightening! In these days of cell phones and Google it would have taken seconds to look up Versed and find the med she chose was the wrong one. When a person"s life is in your hands you must perform "do diligence. " Your analysis is absolutely correct.