Nurse RaDonda Vaught Convicted of Homicide? A Doctor Explains 

This is just my humble opinion as an RN for 22 years. I would never, ever, ever recommend that anyone become an RN, because it sucks! The helping people part, that all nurses go into it for is all but gone. It's all paperwork, computer screens, subervience, running on maximum for the entire shift, no breaks, not even to pee. Cannot recommend. This is just so sad.

The fact that Vanderbilt tried to hide this shows you that this nurse is just being made an example of to cover up for the fallacies of their entire institution 💯

Retired RN after 39 years. Unbelievably difficult profession. Why would a nurse have access to this type of medication in radiology?

never seen a doctor defend a nurse before, thank you

As a nurse thank you for taking a stand for us. Unfortunately we are going to have a huge problem in the future of nursing because there wont be enough of them.

The hospital and system as a whole throw nurses under the bus. I’m a retired ICU nurse. It became increasing difficult to impossible to give patients proper care due to all the boxes that had to be checked per computer and redundant paperwork. Horrible understaffing issues and constant demeaning with no backup from anyone.

Been a nurse for 16 years. I'm on my way out. I'm going into software development. I actively discourage people from becoming nurses. The workload is inhuman. Employers will offer you up for sacrifice in a heartbeat. No matter how hard you try, nothing is ever good enough. It sucks. Now being vulnerable to criminal charges for not being able to keep up with a workload that no human can do and to be held to a level of perfection that is virtually impossible is nothing more than throwing your life away deliberately to be set up for failure.

Amen to Vanderbilt having trouble recruiting nurses. As a nurse of 38 years I am so disappointed in the changes in healthcare and how we are able to care for patients. Every nurse has or will make an error, fortunately most do not cause harm. God bless RaDonda Vaught

This story is why I left the bedside. There were so many situations, daily, that sound just like this when I worked in a hospital. Being a hospital nurse is the highest stakes, highest stress job. Nurses are the people executing every order that is placed and the only true patient advocate at the same time. We are charged with the safety of each person and required to put them at risk with every order we carry out. Thank you for sharing this!

I’m an LPN graduating with my RN in May, and the only place my school has promoted the entire time is a hospital for work. Well, I have worked 16 yrs in a rehab setting, and on a respiratory unit, and I can’t tell you how many times upon admissions I have found WTF errors. Not just nurses, but MD errors as well! I received patients from the hospital who NEVER should have been discharged in the first place,and I had to turn around and send them back to the hospital!Our healthcare system is broken, and the nurses are being used as scapegoats! Watch a mass exodus of nurses in the next few years!

As a nurse for over 40 years I would never recommend a career in nursing, it's a nightmare profession now. Like everything else, it's all about the bottom line.

I believe in the local paper in Nashville it was stated by the journalist that the patient's family was aware of the error. They had not been made aware of what occurred with their Mom at the time, but even when everything came to light they did not vilify the nurse. That should speak volumes.

As a future nurse this is terrifying. Even as a cna, I’m overworked ridiculous ratios so I can only imagine accidentally making a mistake as a nurse.

I'm not a nurse but I know that overworked, burned out people in precarious iffy systems concerning safety are bound to make unspeakable mistakes. Nuclear powerplant safety protocols, surgical protocols, aviation protocols etc. are supposed to be carried out by clear headed, rested, "present" people. When you put so much pressure on people, fatigue them and force them to go in autopilot, you create a recipe for disaster. Unimaginable disaster like this.

As a healthcare worker, I was often told I should go back to become a nurse. I thought about it, but ultimately I decided against it, because I saw first hand the amount of BS they have to go through and the little to no support for the floor bedside care staff. Its too stressful.

Thank you Z, for standing up for nurses when no one else does. I did forty hard years as an RN, twenty five in hospital, fifteen in a cardiology clinic doing triage for eight cardiologists. The clinic was a cake walk compared to the hospital. It squeezed everything out of me. I am a detail oriented perfectionist and rule stickler, but I made three medication errors in those twenty-five years, because the demands of the job were always at max capacity. Luckily, those patients were not injured, and I went through the reporting and disciplinary protocols, and felt like crap. We are only human, but the system demands super human.

I gave birth in November & my brand new baby spent eight days in NICU on a ventilator due to nurse error. But I made sure that the administrators did not fire the two nurses who caused her injury because I genuinely felt like they did their best & took as good of care of my baby & me as they could have given the circumstances. The hospital assured me that their protocol is just culture. One of the nurses took a photo on my phone of my husband & I holding one another in our sleep in the hospital bed once our daughter was resuscitated & stabilized & I will cherish that photo forever. The nurses both were devastated by their mistake & kept close tabs on our baby's condition while she was in NICU. It was undeniably their mistake, but it should not cost them their career. & I'm relieved that it didn't.

Yep, my neighbor is a nurse having just graduated three years ago. Already having enormous amounts of stress from attempting to look after 15 patients a day. After the news came out that RaDonda was convicted she is now starting a new career as a Recruiting Agent working for a large Employment agency. Four to five years of education and enormous tuition fees voluntarily flushed down the drain simply so she could have some peace of mind and be free of the already overwhelming hospital craziness. She wanted to be among the first to leave the profession rather than face the ever increasing burdens and patient loads that will be forced on the last to leave.

This is exactly why I left bedside nursing and went into aesthetics. I worked in the ER/ICU. Nothing but short staffed, overworked, underpaid, and disposable to the larger hospital systems. This conviction is a disgrace to all medical professionals and it will cause already bad issues to become worse.

No one wants to even TRY to understand how difficult being a nurse really and truly is hard as hell. Everyone thinks we sit around and talk and drink coffee and are lazy. We sit because it may be the few fleeting moments in a 12 hour shift we are actually ABLE to do so. We drink coffee because our jobs are physically and mentally exhausting and caffeine is sometimes the only thing we have to keep us going because we didn’t get a real lunch break. But when we make a mistake, we aren’t supposed to be human and now we are criminals on top of it. What happened was tragic, but putting a nurse in jail because of a med error proves nothing and accomplishes even less.

ZDogg, you're late to the party. Increasing criminalization within medicine has rocketed the last 10 years. You're absolutely right to bring up the "systemic errors." The Pixis releasing a medication with only 2 letters entered is an "administration" issue. With the thousands of medications, no distribution system should dispense a med with only 2 letters entered.

At this point, I don't know enough to say whether or not this was a criminal event. I am a seasoned ICU/ER/Flight RN and a boarded ER NP. I don't understand two parts. 1) Versed is a fat vial in brown glass and typically a green top. Vecuronium is a powder in clear glass, with typically a red top. It must be reconstitued. That alone should have triggered something in her mind. In the ICU, versed is given regularily. 2) when would you give an IV sedative and walk away and leave a patient without monitoring. Especially an older patient with a head bleed. As I understand the situation, the nurse was an ICU nurse. She should know standard of care. I wasn't there. But on the surface, this seems so off. Vecuronium is survivable if she had stayed with the patient. Bag valve mask would have been enough to keep the patient alive. Again, I wasn't there. But I find these events difficult to wrap my head around. Medical errors happen every day. If the error was genuine, then it shouldn't be considered criminal. We couldn't function in health care if medical errors were treated as criminal offenses.

They float us, we are treated like a heartbeat with a RN license. For my whole career, I was afraid of hurting someone. This has been going on since the 80s when I graduated. My heart goes out to her, couldn’t imagine the pain each day she is feeling.

Aight I was with you until you explained all the errors she made: not typing in the generic, not reading what drug she selected, ignoring the pop up warnings, not reading the name on the label/the warning on the label, not realizing the drug she needed was liquid when the drug she selected was a powder, etc. This is just malpractice. There’s no excuse for this. You can get put in jail for manslaughter for just being negligent in a normal situation. This was more than negligence, this was willful ignorance in an environment where you KNOW there are life and death consequences.

I have been teaching nursing students now for 17 years. During that time as I observe what is happening on different units, I have seen an increase in dependency on technology and an increase in specialization within medicine. The result is too much dependency on technology without using critical thinking skills and too much focus on charting with less time at the bedside. The ultra specialized focus of providers also means gaps in appropriate treatment and communication which can result in patient harm.

I love listening to you because you hit the nail on the head everytime. As a nurse I know how it is and unfortunately unless someone is in our shoes, they wont realize the struggles we face each shift. One has to be in it to know it.

Thank you for supporting her. In public.

Thank you for addressing this issue. I’m a nurse practitioner and I worked in a system (not my hospital) where nurses would beg me to cover their errors with an order because the nurses would get punished for any med error. This is so sad! Everyone has made a mistake but it’s really important to find the root cause of the error. If nurses fear retribution, errors will never be reported and the issues can not be fixed.

Just adding to our understaffed nurse issue. Being understaffed= being overworked. Being overworked= stress and mistakes. This is so sad.

Unfortunately, it appears that these hospitals are “too big too fail” as happened with the banks. The money given to hospitals and universities is so large and becomes a conflict of interest in regulation. This is very sad for all medical professionals and more so for patients and their safety.

I can relate a lot to being normalized to alerts/messaging etc. I’m a pharmacist and sometimes after a long day, in a chaotic environment, verification fatigue is something that’s very concerning to me. You can almost see a name of a drug that you know should be there when it’s not. Pop up for everything, your fingers almost hit the button without you even consciously processing you’re doing it. It’s hard to explain if you haven’t had the first hand experience. I can also understand even reconstituting something under pressure. When you are distracted and doing a task that’s so familiar to you, it’s not always as simple as, “this drug is never in powder form.” I think it’s human nature to kind of go into a robotic mode when you do something frequently enough. That’s why it’s so important that the hospitals or systems you work under are well designed and well executed. The scrutiny is misguided. Intent and root causes are so important in situations that are bigger than the incidents themselves. Her intent was not one of a criminal; the remorse and devastation are evident. The root causes however, those are alarming. The focus needs to be on how insane it is that this person was working in such an environment that it seems bizarre she could make this error. Not that she was insane for making it but that she could have made it based on circumstances as practices of that hospital.

What this will serve to result in is so far reaching it mind boggling. No one will feel comfortable reporting medication errors and there will be fewer people going into a profession which is already suffering a nursing shortage. Vanderbilt actually covered this up. Those perpetrating the cover up should be charged too!!

Preach! Imagine a cop or prosecutor getting put in jail for wrongly sending someone to the death chamber or a firefighter accidentally injuring someone saving them out of a window. If that were to happen people would be on the streets with pitchforks. This woman made a terrible mistake and should probably lose her job. But unless there is intention to harm, the responsibility falls upon the institution.

The system needs a complete overhaul. This should never happen. However tragically there were too many mistakes made by DaRonda. "One unfortunate oversight/error" is one thing, but just way too many on her part - but she is certainly not entirely to blame. I finished one year as RN student (mid 2000s) and saw truly unacceptable errors by nurses - more than I could have imagined prior to me being in nursing school - that should not happen - IV tubing falls on floor as it is being replaced and catheter/port end did not even so much as get wiped/disinfected - just hooked right up to the patient;;; changing dressing for deep foot ulcer in diabetic patient /wound care -- and nurse pulls wastebasket closer to patient mid - dressing change and does not change contaminated gloves that touched the waste basket ... others as well but don't want to write an essay here. The reality is nurses are set up to fail in this awful system we have - - they are so overworked - I cannot even imagine it now. I will repeat this again - the system needs a complete overhaul. Will this case be the force for this needed change? We finally got universal health care -- now we need universal medical error/system reasonable protections.

RN for 30 years and this breaks my heart all around. I wouldn’t advise anyone to go into nursing these days, especially, after this. This is why we need nursing UNIONS to hold administrators responsible for providing support for nurses and all hospital staff. Patient safety over profits.

All that needs to happen to fix this situation is not having meds auto-populate on the pixis when you type in 1 or 2 letters, it's not rocket science.

I’m an anesthesiologist. Not monitoring an elderly pt with a head bleed that you are giving sedation to IS criminally negligent. The accidental med swap is not criminal despite the many context clues that she was doing something wrong. However, even if she had only given Versed, she still could have killed this pt due to the obvious lack of monitoring. At minimum, an ICU RN should be monitoring this pts respiratory rate after giving sedation. It’s obvious she gave the med and walked away. This IS criminal and not a simple mistake. The med swap could have been a simple mistake. However, even with the accidental med swap, this pt did not have to die. And should not have died.

I am an MD and at one point several years ago we implemented an EMR at a state hospital that was weak. The MD job went from writing orders to putting them into the system ourselves (like the secretary had done) but the system was full of things requiring override, to the point where no one could enter anything without having done at least one override. The fatigue is real. Also, if the patient was there for a subdural (which is what I heard somewhere), then why would she be getting a PET scan at all?? There are some brain bleeds that are cancers but those aren’t usually subdurals and generally the intraparenchymal tumors aren’t visible with the blood still present. If she was stable enough for discharge then why not set up the PET as an outpatient? Great summary of the system issues and lack of accountability where it is needed.

Former lawyer here. This absolutely is negligent homicide. Negligence just means carelessness. He thinks it’s outrageous that killing a patient after half a dozen alarm bells went off was found to be carelessness?! He’s even mad she got fired. Another ZDogg outrage that when patients get killed it’s outrageous that medical professionals suffer a consequence or are criticized. Enough already. He also says that she was convicted of reckless homicide. Recklessness and carelessness are two different standards. Recklessness is worse than carelessness. So he’s wrong. Once again he doesn’t know what he’s talking about, so we don’t know what really happened. And yes, Vanderbilt was much worse than the nurse and should have been punished. Does NOT mean the nurse should not have been. He is right that we do have to change a lot about medicine which kills far too many patients. But that also includes changing this culture of negligent homicide of patients being ok.

I’ve been a nurse for 14 years and I’m just done with healthcare. This poor nurse. We are all her. How the hell can she be given criminal charges for an error? My dad with multi organ failure was deprived of 6 Liters of oxygen for 30 minutes by an ultrasound tech that told him, “You can’t have my tank,” and pushed him in the hall with no O2. That’s deliberate indifference and she still has a job. Joint commission never responded to my complaint either. Yet a nurse was honest about an error and was thrown under the bus and backed over. Shameful. I work in a hospital that cohorts COVID patients in double rooms not knowing what variant they have. WTF? Moral injury is taking its toll. I’m a 14 year nurse about to exit ASAP.

As a travel nurse, I have to regularly navigate a variety of different medication rooms and EMR’s and I find this very worrisome. Why in the world would any hospital have Vecuronium available anywhere but in a crash cart or in the ICU? It should be a two RN sign off like insulin or heparin. Mistakes happen and when they do, they are absolutely devastating to all involved. Which is why a full disclosure of events is encouraged, in order to help mitigate the possibility of reoccurrence and to help keep patients safe. If a nurse feels as though she may go to prison for an honest mistake, My God how is that going to help anything? I can’t help but wonder if she’s being railroaded somehow to protect the hospital?

There were non technology safety measures in place which she did not follow even though she had a trainee with her.

My first LVN job was at a senior living facility. It was part of a huge national corporation that has locations all over. During my second week of orientation, I made a med error. For context, this facility was set up kind of like a hotel, with 5 or 6 floors. I figured each floor had a couple nurses with med carts who would pass meds. Nope. They had ALL the residents wheel themselves onto the elevator and go to the 3rd floor "med room" to take their meds. All at pretty much the same time. Imagine a doctor's office lobby-sized room, with a doorway to an office (nurse's station), where we had the computers and meds, with at least 20 elderly people at a time, most in wheelchairs, waiting around for not only their medications, but their topical treatments. I literally had to take a gentleman to the back room to apply his topical penis medication. (wtf?) So the guy training me took me to a computer and told me to start at the top of the list of patients and work my way down. I was still very unfamiliar with their EHR, and there were people sitting around complaining about the wait. I gathered all the pills for the first patient, and brought them to the nurse training me, and asked how I'm supposed to identify the right patient. He looked at the name and said, "Oh, she's the one with the purple shirt and glasses" and kind of gestured in a general direction. I look over and I see a lady with a purple shirt and glasses and say, "Are you Mrs. So-and-so?" And she's all nodding and saying "Yes, dear." I give her the pills, she takes them, and I turn to walk away and see another woman with a purple shirt and glasses. Holy shit. My first med error. I told the other nurse about my mistake right away, and he got all bitchy and told me to go sit in the back. Later on, the manager boss guy (who was never a medical professional of any sort) reamed my ass. I can't remember his exact words but he made me feel terrible. I tried to explain that I was still learning and that the situation was really confusing at the time, and that I'll never do this again, etc. He didn't care and pretty much told me I would be fired if I did anything like that again. I, of course, quit without notice. Boss man was all, "So you're not giving notice??" I told him that I still had three weeks of orienting left; I didn't think giving notice made sense. Turns out, he was planning on making me work NOC shift alone for the next week. The lady I gave the wrong pills to turned out to be fine. Most of the meds were actually the same ones she normally took; there was one other, can't remember which, but the doctor said she would be fine. They had me call the lady's daughter and tell her I gave her mom the wrong meds, but the daughter was so nice and understanding about it (I apologized profusely; I felt so bad). So, yeah, that was my long-ass-winded way of saying that I, too, am RaDonda.

Healthcare is so under staffed. You can't expect people to not make mistakes. Their is no help for healthcare workers. I'm a CNA and I run from room to room. No lunch, no break, getting yelled at by family, patients and most days we have 12 to 18 patients. Healthcare workers can't give good quality care if they have too many patients because of under staffing. I love my job and wanted to look into nursing but no longer.

How could something like this happen. Not the med error the conviction. I'm a nurse of 45 years and I CANNOT believe the direction that my beloved profession is going.

I resigned from a workplace because of how the company continued to run understaffed while over admitting patients leading me to cut corners and lower standards in order to survive the shift. As a nurse we can easily become complacent or overworked, especially nowadays. We have a responsibility to our patients and to ourselves to check ourselves when this happens, make the changes needed and/or walk away. And yes, EPIC is trash. On a second note, I'm really interested in the opinion of who she was training when she pulled the wrong med.

How hard is it to double check the name of the medication before administering it? I don’t get that it’s hard for anyone? Lawyers double check and recheck their documents (word by word). But they can’t check name of the medication right before giving it to a patient? What am I missing? We are talking about human LIFE not a word error or a headache or a cut. This is LIFE and DEATH. Come on.

1. I’ve made med errors. 2. I bawled my eyes out for days over things that hurt no one, but they *could* have. 3. We can’t remember literally everything with all the distractions we manage. Systems need to make our jobs easier - not harder. The system has the potential for software that handles all the pt rights. We need it to be in place.

Did anything else happen to Vanderbilt? Did they lose funding? Were they sanctioned? Anyone else fired? Their system was jacked up. They buried vital info and threw the nurse under the bus

Working at risk management in a hospital I am shocked and the hospital should be held responsible for the cover up.

I don't know. This was a MASSIVE medication error made even worse by her being an actual ICU nurse. I initially assumed she was a new grad/ or non- critical care nurse, first-day- on the job scenario. I don't understand the confusion, she literally just had to verify the name of the drug. I am an OR RN so i don't pull drugs out of a machine, but i sure as heck know how to read the label on a vial. Yes, technical issues are a pain and have the potential to complicate our job but that isn't an excuse or explanation. Criminal charges though??? Hmmmm. I would also consider the nature of the drug error that would've delivered the most agonizing death to that patient imaginable.

There is no way to ACTUALLY accomplish everything a bedside nurse is SUPPOSED to accomplish in any given shift.

There are so many problems with this case to list. But for me, you shouldn't be able to override vec ever, and if you are in a area that requires a paralytic, it should either be in a crash cart, intubation kit or the pyxis but needing to be approved. Also, the nurses in this area had to override over 30 medications that day due to communicating errors in the system. So many red flags, and one person thrown under the bus.

CICU/PCU RN for 13 years👋 30 seconds in i couldn't listen anymore🙄 RNs...Have you ever overrided a high risk CNS depressant you weren't familiar with in a non-emergency in front of an orientee, ignore the drug name in the pyxis, reconstitute the drug without looking at the name on the vial (and thus what the correct diluent should be) and then administer that same sedating drug without a barcode scan to the patient and then not monitor her? 🤔 Yea me neither. That's why I roll my eyes when people say "this could happen to anyone". No, it couldn't. This would only happen to someone who is criminally negligent.

Wow. Now that someone has explained this in detail. I actually find the nurse and the hospital to be completely incompetent. There were more red flags than I originally knew about. This practice of making excuses for someone’s mistakes is getting out of control these days.

I remember listening you tell us about this originally and it broke my heart then. This is an awful conclusion for all parties - it actually made me sick to my stomach.

Unfortunately, it appears that these hospitals are “too big too fail” as happened with the banks. The money given to hospitals and universities is so large and becomes a conflict of interest in regulation. This is very sad for all medical professionals and more so for patients and their safety.

All nurses have made a medication error, and those who they haven't, either didn't realize it or are lying. I know I have, and I was lucky enough not to have a adverse outcome. We are all Radonda.

This is sad for the victim and the former nurse. I’m more shocked at Vanderbilt hospital!!!! One of the top hospital in the world wanted to try and keep this a secret pay paying the family not to say anything! Says a lot. I don’t trust anyone after this. She told the truth and she’s in jail but Vanderbilt is free!!!! and off the hook. I changed my mind about nursing school

My hospital just went to EPIC, we've had to override a lot and we don't do double checks on insulin like we used to. It doesn't even prompt you to put in pulse and blood pressure for blood pressure meds. I graduate in 4 weeks from nursing school and I'm legit terrified; most hospital nursing staff everywhere around me is new grads and travelers.

I retired after 45 years as an RN. This totally sickens me. Why would anyone want to go into nursing after this? Why would they have that med in radiology? My heart breaks for this nurse. She has to live with her error daily. 😪

43 years as an RN in critical care nursing, I am glad I an retired. In the military none of the systems talk to each other, let alone from one hospital to another. Our computer system where I worked would not have my patient on any Pyxis but my unit. Could not override it either. If We moved a patient from one unit to another, we could not get ANY meds till the Pharmacist checked everyone of the med orders.

If you believe the cop who accidentally pulled her gun instead of her taser was guilty of negligent homicide then you have to believe that this nurse was as well. Yes, it was an accident, but her negligence led to someones death. Is the hospital ALSO partially negligent? Maybe, but that still doesnt excuse the nurses negligence. This type of scenario happens every day and other people go to jail for it, why shouldnt medical workers?

Do you hear yourself? This was pure negligence and she should be held accountable. My bet is that you are the same people who want law enforcement to be super human and held to a higher standard, but you don’t think you should be? Why?! You are dealing with public health and safety just as they are. It’s sick that you are trying to justify this like it was just a paper cut or something! She could clearly see it was the wrong medication and she left her there alone.

This story makes me so, so sad for ALL involved! It’s a cautionary tale for those of us in healthcare. And yes, so easy to see how it could absolutely happen to any of us.

If this happened to me or my family member I would not want this nurse in prison. Mistakes happen and we learn from them. No one is perfect, prison should be there for true criminals.

I’m an RN, I don’t think I know a single nurse who has never made a med error( big or small). It’s part of the equation being human and working in understaffed units, full of stress, and sick patients requiring ton of meds. Every one of us has en error we learn from and will remember.

GOOD!!!! Everyone should READ PATIENTS AT RISK. And what you mean she purposefully broke protocol and got caught. Thats not a med error. sucks to suck but yes everyone breaks rules and nothing happens but this time it did and should be addressed as such. SHE LITERALLY DIDNT READ THE BOTTLE???? HOW MANY PEOPLE TAKE MEDS WITHOUT READING THE BOTTLE???? You are spot on with a lot of things but this you are completely off. Agree with the hospital bit but she should be convicted. the system prompted her so many times.

The system contributed, as you detailed. The most important facts were the two you glossed over: 1. She was training someone but didn't think about the reconstitution process for vecuronium? 2. She left without monitoring the patient. IDK the full details, and as you said, aspects of this are truly systemic; however, those 2 parts are exclusive to her. Even if you had a 2 nurse system, if both are fatigued, there is no change. The only thing that may have helped would be a bracelet system, but if she can override it, then it's still moot. This comes down to individual responsibility. The fact that she reported herself is venerable but is also an expectation. Had she not done so, the Pyxis (or whatever machine) would still have logged what/ who dispensed the med. So, IDK why everyone is acting as if she was only found out by her own admission. That is unlikely the case. You are extremely disingenuous about what vecuronium does. I imagine it's there for the same reasons it's anywhere in the hospital, emergent intubations. Lethal injection, really? That's good to know but irrelevant to the case. I too am a doctor, and I have and will make mistakes. With that said, the mistake she made fits the legal definition of negligence. She disregarded aspects of her job in haste, which can be excused in lesser cases, but the details in this one are quite concerning. If you can't or don't want to do the job, don't. There are plenty of reasons for and against the industry of medicine. This case won't be the end of the field by any stretch of the imagination. Also, the hospital blame and the administrative blame are separate from her actions. All parties should get penalized (particularly for the reporting afterwards), but she is the root. The role of the system is to heal the patient while preventing the workers from doing something stupid. She did something stupid despite the safeguards that were there. It's interesting that you simultaneously acknowledge and disregard the safeguards that were in place. There could have been more, but you can't protect anyone from every situation. I end by saying there is no right answer to this. Her being held criminally liable is fine, as would her being fired and license revoked. However, her losing her license doesn't stop her ability to engage in medicine (academically, abroad, even by lying in a different state to get a new license elsewhere). The potential fine ($60k, iirc) is more egregious to me than the prison sentence.

Doctors always ask for "Versed" the mar lists it only as "Midazolam". I pointed it out to our epic/pharmacy safety team, they started listing both. Complacency is also a problem when people don't see things through new perspectives. Just because it's always been done doesn't mean it can't or shouldn't be changed.

As someone who studied industrial engineering with an emphasis on information systems on the graduate level, I was stunned that this system was set up so badly, though still puzzled that the nurse persisted. Back in the 80s and 90s, there was a huge emphasis on human factors, on designing systems that made it easier to get things right, but all of that seems to have gone out the window in the name of cost-cutting so we can afford socialized medicine. Anyway, organizing meds by brand name instead of by therapeutic category, just for openers, was a bad choice; I also read about another similar case involving a med that had the same two first letters as another inappropriate one. At least there were warning messages (but maybe too many petty ones.) Designing these information systems is an art, and they need to undergo substantial testing, including with very tired subjects!

Let’s take this back to the court. If a mistake is made in a criminal court, and a person is jailed or put to death should those that served in any capacity in that court be held criminally liable? This would balance the scales for fairness, although justice would likely be right out the window.

8mins in... not watching any more... That is not a med error, that is medical negligence. That is not a medical emergency to over ride something to save someone's life. She should have followed protocol or delayed the testing... I would like to know her history and a peer review. That is alot of mess ups, like she is high and lazy mess ups...

Following this devastating case, our hospital reassessed individual units and removed unaligning meds from Pyxis system. Certain critical meds are placed in higher controlled storage units which cannot be bypassed and will need pharmacy verification prior to authorized dispensation.

Whenever I see a drug I don’t know, I look it up, or call the pharmacy. 21yrs in. The alerts are there for a reason. My condolences to the family of the women that lost her life.

I am a retired (thank God!!) RN. When I was nursing it was well known the med errors were common and were almost Always considered a 'Systemic Problem'. As you said, there are So Many contributing factors, and I can only imagine how much worse this has become with the stresses of Covid, undestaffing, etc. This charge of this nurse will only cause fewer people from entering Nursing.I have a 30 yo daughter who has been in Nursing less than 10 yrs and is already considering leaving! I can remember working Psych 12 HR shifts (extending to 14 hrs due to report, sick staff calling in last minute). Frequently no time for a snack or pee break!! And no pension either! I retired in my late 50's due to work related back injuries, surgeries. My SSDI payment (my only income)? Less than $1000/mo, 200% below poverty! I hope and pray people take your message to Heart!!!

Such a horrible way to die. Yes, it could (and should) have been prevented by one last check, but there were lots of places a system change could have prevented it as well. As an anesthesiologist to try and prevent med errors I even had special places on my cart for different drugs : Induction/narcs on the vertically on the right, vasoactive perpendicularly across the top, relaxants vertically on the left. Double checking. Throwing away meds and starting over if someone interrupted and I lost focus of a dilution. (Now we have mats and if we're standing on a mat we're not to be interrupted). Still, I'm human and the job requires doing several things simultaneously (or nearly so) and the system asks us to do more in the same number of hours every week. Focus can be divided. Using the EMR and Pyxis there is an easy way to track times and heaven forbid if you don't meet the time metrics. There but for the grace of God go I. Hopefully everyone learns something that will be useful going forward, but the chance of others honestly reporting / discussing med errors to try and make other system errors just got smaller. Lots of room for system changes that you note. There are so many system issues that seem pointless that lead to alarm fatigue (for instance a time outs. I think it's a great idea for critical pieces of information but it's become so bulky with so many pieces of information that people tend to tune it out) When suggestions for improvements come from front line care givers - ones that could actually make a difference - it falls on deaf ears until a critical incident occurs. Honestly the cynical me thinks most of the system 'improvements' are in place to facilitate billing.

Nurse here….bottom line protect your license, do proper basic nursing, don’t get complaint because you have technology. Protect ur license!!!!!

Hospitals can be the absolute worst; management just doesn’t have your back. They’ll run you ragged for unfair pay, charge the patients through the nose for it and if you’re fatigued or overwhelmed that’s your problem. It’s not about patient care or staff retention anymore it’s all about the bottom dollar

Healthcare is changing, how about the abuse nurses get from patients? Get a new career folks, go do something else.

😳😔 There but by the grace of God go ANY health care provider!!! God help us all enduring this precedent!

Who is going to want to go into nursing after this? Unacceptable, Vanderbilt tried to sweep it under the rug

I'm a 20-year experience ICU nurse and have worked in over 25 hospitals around the country. I have probably onboarded or precepted 200 new nurses in my career. My first year of nursing I was working PRN agency in interventional radiology and doing conscious sedation on a patient having a peripheral angiogram, I had only been at this facility a handful of times, it was my first time in my career working IR and doing conscious sedation. I believe at the time we were using possibly morphine and valium, IV fluids, and I was sitting at the head of the table with the patient on the monitor a foot or two away. During the procedure, his condition and presentation started to change so I alerted the doctor and the scrubbed in IR nurse, and they proceeded to finish the angiogram and then the patient was brought to the recovery area and within a couple of minutes he was coded. I believe he ended up with a PE, or perhaps it was an MI on the table, he ended up in ICU and they withdrew care the next day. All that being said, 25,000 bedside nursing hours later, I still remember it like it was yesterday... that was just one event. I remember hundreds of events which become part of a person's mental framework, whether you're a doctor or a CNA finding a patient on the floor that just fell. 20 years ago there was no epic and hand scanning and all of that and in my example above, there was no medication error made, but that's not to say that throughout my career I haven't made any. Just like that truck driver that got all of that uproar when his sentence came through for that horrible situation in the Colorado mountains where he lost his brakes, I find it hard to believe that nurses can't join together with their numbers, and be supported by the doctors behind them such as yourself, much appreciated by the way, and figure out some kind of way to collectively voice and move the needle in the direction of getting this poor girl off of criminal charges (I am not in disagreement necessarily of the nursing board's decision however.) This could have been me. This could have been any of us. Maybe not as high probability in today's system, but still it is not a flawless system. The reason the trucker was given consideration was because of other truckers potentially refusing to move the goods through that area. Imagine if the nurses said well we're just not going to work Icu, we're just not going to do conscious sedation, we're just going to choose types of nursing such as clinic nurse or informational technology and not put ourselves in this position. We need ICU nurses. We need nurses at 4:00 in the morning bringing patients that are unstable and near death to CAT scan. I hope just like the Dr stethoscope thing that somehow there's a movement on this as well. z dog, thanks brother and feel free to holler if there's anything else I can contribute.

As a “retired” RN who got the hell out, thank you!!!!!! I do appreciate every truthful word you said. Floor nursing is a scary shit show and that’s why nurses do not want to work doing that job. Although I miss taking care of the patients. And I miss the comraderie of my fellow coworkers.

Great recap of this entire case! Although you are a physician, and not a nurse..you really hit the nail on the head. Thank you for understanding what we go through everyday. The other day I was asked to pull IV Ativan and take it down to MRI to administer to a confused, disoriented, anxious patient. I had to pull the medication on the unit, draw it up, then put it in my pocket to run downstairs to administer. There was no way to scan the patient, check allergies, look at the order etc. All I could think about was this case. “What if something goes wrong? What if she goes unresponsive?” And honestly, I feel like I had no choice in the matter or else I would have been “talked to” by management for delaying patient care. Everyone in healthcare is putting their license on the line on a daily basis..but more importantly, these hospitals are putting their patients at risk knowing they won’t be reprimanded. They will just fire the nurse, the physician, the RT..and move on.

The fact that she didn’t recognize this wasn’t versed when she had to reconstitute it is baffling. Was she impaired? I’m assuming she was drug screened (sorry-I haven’t had time to listen completely yet-maybe this is discussed). BUT MAKING IT A CRIMINAL ACTION IS WRONG. I AGREE WITH EVERYTHING YOU SAID ABOUT THIS ACTION HARMING PATIENT SAFETY. Thank you for your videos. And yes: I am a Nurse RaDonda. I injected a drop of the wrong med when I realized it, averting a disaster. God helped me realize this error before the patient was harmed severely. Medication errors happen! But we can minimize them with better systems.

Here is where I differ. At the end of the day that nurse had one job and that was to give the patient the prescribed medication. That includes comparing the medication to the prescription. It doesn't matter that it came from a machine. And yes there are other's in Vanderbuilt that need to go to jail.

Also she should have been judged by a true jury of our peers such as doctors and nurses! You don’t understand what we go through until you’ve been in our shoes!!!!

Every nurse at Vanderbilt needs to quit and never look back. I’ve been a nurse for a very long time and with the current environment in healthcare and society, I would never recommend to anyone at this point to become a nurse.

I remember, we had 2 patients with the same name who was admitted few hours in between them on the same day. At the same time, they were born the same year and month but different date. Both of them needed surgery in the head but in opposite side. In addition, both are admitted in the same ward. Dangerous world we work with.

"Admin who set up crappy systems walk..." Could not agree more.

I feel so blessed to work for my hospital, and my department in particular. It’s far from perfect. We have our staffing issues, particularly in the past two years. We have burnout. But our nurse/patient ratios are far better than the national average. My department in particular has an excellent culture of teamwork and collaboration. We have excellent managers who are constantly roving the unit and offering practical help when needed- not just “great job! Here’s some pizza!” We have the systems in place to report and address safety issues. I had an adverse medication event occur once. The outcomes for the patient were fine, but it could have been bad. I was called in with the whole team that was following the patient. We went over what happened. The order sets were evaluated for appropriateness and changes were made to improve patient safety. There were no repercussions to anyone. Our administration… well, the best that can be said is that they support patient safety and nursing because it allows us to keep our Magnet status, which gives the hospital prestige, which keeps them making money.

2 nurses in our family and I just feel sick about this… error, Licence lost I see or re-training If her PTST not too bad, but jail! OMG my son needs a new career because bypassing happens all the time where he works because of insane overwork, no company investments in infrastructure, and horrible schedules and hours. Time to dump nursing ASAP

Thank you for speaking out and giving the other side of the story. People who do not work in healthcare have a hard time understanding how the system as a whole is set up. One of my co-workers used to say we ran around on bloody stumps, she was right. Nursing is not what it once was, it has been on the downward slide for years because administration has developed a new model for nursing. They talk the talk but it's called lip service. Mable Lamberson would be so disappointed today at how nursing has been veering away from patient care and loaded with charting, new systems, and big brother. Administration never worked a day in the ICU, OR and specialty floors yet they lay out the plans and dictate how the work should be accomplished in less time and with less help.

This reminds me of the case in Toronto in the 1980's where a nurse at the Hosptial for Sick Children was accused of killing mulitple babies in the cardiac care wing. The nurse when to trial and was found not guilty. 40 years later the figured out the cause - compound found in seals on IVs and syringes. At first, it was thought to be a labeling issue between the medication & a vitamin.

Epic is a horrible system, and so not medical professional friendly ONLY profit friendly

I guess I'm just not convinced that the context should change the criminality of her negligence. She was still so negligent that she accidentally killed a patient. Yes, it wasnt entirely her fault, but a change in her actions alone could have prevented the outcome. Will this result not reduce the alert fatigue of others? Also, while it probably wont happen, the system's failures should also be held accountable in some way. Why should the government not come in and overhaul things?

She brought the vecuronium from the ICU where she pulled it from the Pyxis. It wasn't pulled in radiology.

I almost died bc I was sent home after being in the ER with a PE. I had the increased lab results they look for before giving a CT and was still called a "little girl" by the doctor and mocked for reading too much Web Md. Because I had no preexisting conditions to put me in a high risk group that he saw (I have several autoimmune disorders) he mocked me and sent me home despite the test results. Thankfully when the morning shift of radiology came in they caught his mistake and called my husband at work, I was at home asleep on the meds he gave me to sleep. He was in tears thinking I was dead by the time he shook me awake. All of that said I would never want him or anyone else involved to go to jail. They DID catch it at the end of the day. Could I have sued, maybe. Would I feel comfortable him losing his career because he doesn't take sick women seriously, no. We need all the doctors and nurses we can get. I did have a personal talk with him and told him what happened to me is many woman, especially WOC worst fear while in the hospital. We aren't hysterical, we aren't just overly emotional because of hormones. We are as capable as our counterparts and these misses because we are looked at as "little girls" need to stop. He cried and I cried. I am hoping it was a wake up call for him and his colleagues. Just my 2 cents.

My greatest fear is having to go to the hospital outside of a general visit.