EP 157: A Nurses Perspective on The RaDonda Vaught Case

EP 157: A Nurses Perspective on The RaDonda Vaught Case

Medical Errors and the RaDonda Vaught Case

The RaDonda Vaught case is controversial because of its nature – Vaught being a nurse and how her actions led to the death of a patient. As one of the leading causes of death in the United States after heart disease and cancer, medical errors rank third. But why is this so? What are the common medical errors that can happen to a patient? Is there a future left for Vaught?

In a study done at John Hopkins in 2016, more than 250,000 people in America die of medical errors each year. Other reports indicated that the numbers are as high as 440,000. 

The RaDonda Vaught Case Overview

Miss RaDonda Vaught was a former nurse from Tennesse. She was accused of dispensing the wrong medicine, which led to the death of her patient. Her trial begins this March 2022. Because of her actions, she was charged with reckless homicide and felony abuse of an impaired adult. 

The RaDonda Vaught Case’s Timeline

To get a better view of what this case is all about, here is the timeline of events:

Dec. 24, 2017 – Charlene Murphey was a long-time resident of the Nashville suburb of Gallatin. She came to Vanderbilt with a subdural hematoma. A subdural hematoma is also known as bleeding in the brain. 

Dec. 26, 2017 – Two days later, Murphey’s condition showed improvement. She was almost ready to be discharged from Vanderbilt. She was then sent to get her final PET in the radiology department of the hospital. Murphey was supposed to be given a sedative called Versed.

Unfortunately, instead of the said sedative, she Murphey was given a dose of vecuronium. This drug is a powerful paralyzing medication. According to federal investigations report, this drug left Murphey brain dead.
 
Vaught allegedly admitted to hospital staff that she was responsible for the said medical error. She stated that she went to the Pyxis that released medications and realized that the patient’s prescription had not been sent over
 
She then overrode the system by typing “ve” and selecting the first medication that came up. The drug she chose was Vecuronium bromide, which is a paralytic. 
 
Murphey was found unresponsive after 30 minutes and required CPR and ventilation. Although she was placed on life support, she died after 12 hours. 

Dec. 27, 2017 – Murphey’s family gathers at Vanderbilt to say their goodbyes. She was then disconnected from the breathing machine, calling her time of death around 1 a.m. 

Plaintiff vs. Defendant

Assistant District Attorney Chad Jackson said there is no way to prove that Vaught could have pulled the right medicine from the machine with the way she used it
 
Vaught’s attorney, Peter Strianse, said he plans to show that the medicine-dispensing cabinet was in permanent override mode.
 
A reckless homicide case can carry a sentence of up to 12 years in jail, while impaired adult abuse carries a penalty of up to 15 years.

Updates on the Court Case:

The plaintiff asked the defense counsel not to ask any witnesses. This was about the actions done by Vanderbilt University Medical Center. And the measures are taken by VUMC after the victim’s death. 
 
It is not out of willful neglect, so why should the defense not be able to ask questions? We should look at the whole picture and details. 
 
For one, we are looking at the vacuum problem of the machine. It is like half of the situation was not taken into consideration. As nurses, we need to support her. 
 
The defense counsel couldn’t bring up the patient’s family’s settlement with Vanderbilt University.

Conclusion: Anyone can make mistakes, but medical errors aren’t the result of just one person or party. 

How does the nursing profession feel about this?

RaDonda Vaught’s case could have been a mistake that caused her career. It’s crazy that each shift as healthcare professionals could cost us our careers if we don’t pay close attention to detail.
 
Talk about stressful jobs! This case has sparked a rallying cry for nurses who worry that honest mistakes can be criminalized and they can lose their jobs.
 
This case also has a few loops that can cause future problems for the hospital. The hospital did not report the fatal medication to the state that caused the error, as required by law.
 
The two Vanderbilt doctors told the medical examiner that Murphy died a “natural” death. And that her cause of death was an intracerebral hemorrhage. The government regulators didn’t discover this error. Then they got an anonymous complaint ten months later.

Medical Errors

Medical errors have a huge cost on healthcare. They cost about $20 billion per year. This leads to more expensive interventions needed to correct or treat more issues.

Reporting Issues of Med Errors

Despite medical errors affecting so many patients, it is often unreported. In 2017, the NORC at the University of Chicago surveyed medical errors and patients’ experiences with them.
 
This survey of adults found that in 32% of cases where a patient experienced an error, the health facility informed the person of it. Sixty-seven percent said no one told them.
 
The CDC fails to classify errors on a death certificate when collecting health statistics to paint the bigger picture. This problem makes it even harder to know accurate data about how often these med errors occur.

Why Medical Errors Happen

Working in a hospital can be chaotic at times. Nurses handle all kinds of responsibilities. From taking care of patients, doctors’ orders, and working with other healthcare workers. Adding up to these are administering different types of medications and operating machines.
 
These are a few of a nurse’s responsibilities to help provide the best patient care. It can be a stressful environment and nurses are human beings. They cannot do everything with precision and medical errors cannot be avoided. But what are the most common medical mistakes?

The reason why medical errors occur in the hospital:

  • Communication problems
  • Staffing problems and workflow
  • Inadequate policies and ratios
  • Inadequate information flow
  • Patient-related issues
  • Technical failure

Think about the most recent time a medical error was made in your care of someone close to you. 

  • The mistake was made during a test, surgery, or treatment.
  • A medical problem was misdiagnosed.
  • Received a diagnosis that didn’t make sense.
  • Given the wrong instructions about follow-up care.
  • Administered the wrong medication dosage.
  • Received treatment that was not needed.
  • Were given instructions from different providers.
  • Got an infection after hospitalization or treatment.
  • Received the wrong medication from a pharmacy. 
  • Fell down or fell out of bed.
  • Got bedsore.

Watch the full video on this episode here and learn more about RaDonda Vaught’s case👇👇 :

TIMESTAMP:

00:00 Intro
00:49 Plugs
02:09 Episode Introduction
03:00 Medical Errors Happening in the United States
04:52 The RaDonda Vaught Case
06:29 How and why did the patient die?
10:50 Plaintiff vs. Defendant
13:31 Time versus the SOP
17:03 The misinformation about the drug
23:07 Reporting issues of Medical Errors
25:50 Why Do Medical Errors Occur?
29:12 The system of double verification
31:00 Common medical errors recently committed
33:47 How to Prevent Medical Errors
36:38 Wrapping up the episode

 

 

EP 88: Nurses Coping with the Death of Their Patients

EP 88: Nurses Coping with the Death of Their Patients

Nurses Coping with the Death of Their Patients

Nurses coping with the death of their patients must be normalized within the work setting. After all, nurses are human beings with emotions. But the question is, how do you define death? How comfortable do you feel with death? 

I never imagined being the last person on someone’s chest, keeping them alive before they call the code. Walking into your shift as a nurse, you never know what to expect. You receive your assignment at 0700/1900 and have an outline of your night. At around 2200, you hear the central monitor room alarming. Your heart drops. Is that your patient? As you sprint to your room, the charge nurse begins to scream your name. Your fellow nurse has already started chest compressions on your patient as you walk in to help during the code blue. 

Everyone watches the clock during the code every 2 minutes to administer rounds of epinephrine, compressions, ventilation, and a defibrillator on standby. How was your first code? Do those scenes speak to you? We all know that feeling when the team calls the code. That silence, respect for everyone in the room, a moment in silence. 

Death of a patient: The Family Dynamic 

No book in nursing school can prepare you for the reality of dealing with death. Death is a natural part of life, but that doesn’t make it any easier. One of the most stressful and emotional parts of having patients pass away on you is being there for the family. 

This is a part of nursing where we don’t receive enough education. We practice treatment, knowing how to take care of patients. I know my ACLS. I can save your life. But when we can’t save them, this is where dealing with family comes in. 

My #1 piece of advice for dealing with families dealing with grief.

Silence. 

I tend to be talking, so I have always tended to say something during a sad situation at work. I learned that no matter what you tell someone, you can’t do or say anything to help them. Grief is a solo journey. No matter how many people tell you they are there for you, it is a lonely walk.

The Blame Game

How do you respond when things go wrong? As nurses, we have those moments reflecting, thinking, what could I have done differently? Second-guessing ourselves after we have experienced a harmful situation is a natural process. 

Please do not try to blame yourself and try to find things with what you did when someone codes on you. This is especially important for a new nurse. Are there times when a situation could have been handled better? Yes, of course. This is where experienced nurses can share their knowledge and guide you on what to do the next time you are faced with that exact scenario.

How to Deal with the Death of a Patient

Nurses coping with the death of a patient must practice self-care.

  • Grief affects the body mentally and physically. It’s essential to care for yourself physically as well. Make sure to get enough sleep, exercise, and eat a healthy diet. 
  • “If we don’t do our inner work and stay connected to our quality of life, we can either over-identify with the dying and become lost in that experience or develop armor for protection”.

Know it’s OK to experience joy.

  • We must allow ourselves to experience humor and joy in the face of the dying process. “Any hospice nurse will tell you there’s often an amazing amount of gratitude and inspiration at the end of a patient’s life”. Humor also helps to relieve stress in unique ways. Death is part of the human process.

Remember, it happens.

  • You’re likely to begin scrutinizing yourself after a patient’s death. You’ll wonder what you could have done differently, and you may feel guilty for something like an instance when you were impatient or distracted. Remember, no one is perfect, and death happens to even the most attentive and compassionate nurses. There may be things you can learn to be a better nurse, but blaming yourself is never helpful.

Remember, you’re making a difference.

  • Death is neither a failure nor the end of the patient’s care. Part of being a nurse is not just serving patients but their families. Some of the most meaningful moments in a nurse’s career are working with the patient’s family. Whatever you feel after a patient’s death, the family will feel much more.
  • Nurses are often the first people the family encounters after the loss. How you treat and talk to them is an extension of the care you provide to your patient. You can make a tremendous difference in their lives, which will help them cope with loss—and it will help you too.

It’s good to talk, remember that.

  • One of the greatest assets a nurse has is other nurses. Death and loss are so prevalent in the healthcare field you’re often surrounded by coworkers and colleagues who have experienced similar situations. Whatever you’re feeling, your coworkers have felt it too, and processing your emotions out loud with another empathic person does help.
  • Colleagues can relate similar stories or offer advice for coping mechanisms and rituals they found compelling, and they can help you figure out how to talk to family members who have just lost their loved ones.

Let’s normalize nurses coping with the death of their patients here; click on for the full video 👇👇👇

TIMESTAMPS:

00:00 – Intro
00:15 – Welcome to the show
01:30 – Death in the ICU
03:50 – Dealing with the Patient
08:00 – Dealing with the Family
10:05 – Post mortem care
14:18 – Gift of Hope
16:50 – Don’t play the Blame Game
19:20 – Coping with the death of a patient
21:52 – How to deal with death
24:02 – When a patient passes away
32:47 – Closing the show