[Shuang1]

That case goes far beyond med error and I don't understand why people keep bringing it up as an example.

She pulled the wrong med, and then injected it and walked out of the room rather than observing for effects. Also the med she pulled had warnings on all sides of the bottle and on the top saying very clearly that it's fatal to administer without ventilation. This went beyond a mistake to negligence.

[js2]

Janie Harvey Garner, a St. Louis registered nurse:

“In response to a story like this one, there are two kinds of nurses,” Garner said. “You have the nurses who assume they would never make a mistake like that, and usually it’s because they don’t realize they could. And the second kind are the ones who know this could happen, any day, no matter how careful they are. This could be me. I could be RaDonda.”

https://khn.org/news/article/radonda-vaught-nurse-error-medi...

HN readers can look at this case filing:

https://www.documentcloud.org/documents/6785652-RaDonda-Vaug...

> Also the med she pulled had warnings on all sides of the bottle and on the top saying very clearly that it's fatal to administer without ventilation.

The linked PDF includes images of medicine in question. There's a single warning on top that reads "WARNING: PARALYZING AGENT" and a red cap. I don't see any warnings on the side. The vial appears to be tiny, smaller than my thumb.

But yes, she made a series of mistakes, listed on the last two pages of the PDF.

I am not a nurse, but I can easily imagine how someone could make the errors she did in an overworked and high-stress environment. It's a cascading series of errors that starts with overriding the medicine cabinet when she can't find the medicine she's looking for. But according to her defense, overriding the cabinet had become almost standard operating procedure at Vanderbilt at that timeframe. Once she starts down this path, she's operating on automatic and almost blind to what she's doing.

I agree she was negligent. I don't think she should go to prison for it. In the bigger picture, this is causing more nurses to quit, likely leading to more medical errors and deaths, not fewer.

[JshWright]

> I am not a nurse, but I can easily imagine how someone could make the errors she did in an overworked and high-stress environment.

There are so, so many differences between the two meds, I don't see how confusing them would be possible short of gross negligence (for context, I am a paramedic, and often administer medications (including both of the meds involved here) in a high stress environment).

Vecuronium (the paralyzing drug) is a powder in the vial and you need to first inject saline it into the vial, shake it up, and then draw out the "reconstituted" med. This is very unusual (there are only a handful of medications in common use that require this, and Midazolam, the intended med, is _definitely_ not one of them). The reconstitution process means she would have had to look at the top of the vial several times, and warning on the tops of vials are, again, very uncommon. Also uncommon is the red cap on the vial.

I have made errors before while caring for patients, and I will likely make them again. I am very aware of the fact that we all can make mistakes, but the number of mistakes that needed to be made here far exceeds the standard of what is reasonable, and is well into the territory of "gross negligence", in my opinion.

[js2]

I appreciate your perspective as a medic. The PDF I linked enumerates the mistakes she made and the differences between the two medicines, and I have read all that. From non-professional perspective, it seems like it was inattentional blindness.

But let me allow for a second that this is a case of gross negligence, despite the fact that CMS investigated Vanderbilt and found many other issues in the workplace:

https://www.documentcloud.org/documents/6535181-Vanderbilt-C...

It's not clear to me how criminalizing her mistake helps prevent future medical errors. Do you think criminally prosecuting her was the right decision?

[JshWright]

I am neutral on the idea of criminal prosecution here (for the individual, I absolutely thing there should be accountability for the organization). I am generally opposed to criminal prosecution for medical errors, but it's hard to overstate how outlier this series of mistakes was in terms of the severity of the outcome and the degree of negligence demonstrated.

I think the question of "should we put this person in prison for these actions" is equivalent to any other criminal act (which isn't a clear cut answer either, in my opinion).

[gruez]

>I agree she was negligent. I don't think she should go to prison for it.

but we literally have a law for "negligent homicide"?

[js2]

Yes we do, but we also give DAs discretion over when to enforce it. Given the extenuating circumstances, I don’t think it should have been enforced here.

Her employer, by not creating a culture of safety, set her up for failure.

I just don't see how in the long term this prosecution reduces medical errors and generally disagree with criminalizing mistakes; even ones such as this.

[ikiris]

Enforcing criminal liability for homicidal negligence is how you force respect of even basic safety requirements that already existed.

I'm not arguing that hospitals aren't currently a shitshow, I'm aware I've worked in them. That doesn't excuse this nurse's complete lack of respect for the risks she took.

[js2]

"The beatings will continue until moral improves."

We cannot prosecute our way out of medical errors, and what you claim is at odds with the opinions of medical professionals.

https://www.nytimes.com/2022/04/15/opinion/radonda-vaught-me...

https://pubmed.ncbi.nlm.nih.gov/25077248/

[Sakos]

As I've said before, if aviation insisted on criminal punishment for pilots, we'd be far worse off. Many accidents are caused by fear of punishment. Culture of safety can only be implemented and enforced top-down. Why punish the nurses when they're not the ones responsible for what kind of culture exists at their institution?

[krisoft]

It is a bit more complicated.

We do sometimes punish pilots criminaly. For example one easy way to go to prison is trying to fly a plane under the influence of alcohol. (Here is an example [1])

We do not punish criminaly pilots for other kind of mistakes. For example you are unlikely to go to prison if you miscalculate the required fuel for a flight.

I don’t know the details about the nurse. Was it more like the first or more like the second?

1: https://www.bbc.co.uk/news/world-us-canada-39485928.amp

[chrischen]

That enforcement causes nurses to not want to work, as the nurses aren't the decision makers in making a culture of safety. The administrators bear that responsibility so maybe we should enforce it on them.

[ikiris]

This nurse was the decision maker in whether she bothered to check the label on the vial for what she was injecting to the patient, and / or bothering to scan it as required before leaving them to die in terror.

I'm not sure what world you live in, but I'd like to live in the one where criminal negligence resulting in avoidable death is prosecuted.

[ikiris]

If nurses quit over criminal liability for killing someone by being that careless, everyone is better off by them not being in the field. Pharmacy has had the same rules for over a hundred years. A great example is even in the movie a wonderful life.

edit: minor grammar fix

[kenjackson]

If you don't go to jail for this, do you do so for any sort of negligence? What about an Uber driver that runs a red light and kills a pedistrian walking? Or is drunk and kills someone? That worries me a lot more than this story.

[sithlord]

Literally every medication has warnings slapped all over it. My partner worked at Vanderbilt (on a different floor) around this time, and one constant complaint I heard (prior to the incident) was how there was hardly any controls around anything there.

[JshWright]

Every medication does not have a bright red cap with a bold warning printed on the top (that you have to look at at least twice while reconstituting and then drawing up the med). The warnings on a vial of Vecuronium go well beyond the typical "This medication may case XYZ side effect", and for very good reason.

[ikiris]

Yeah, there's no doubt that this is a shitshow from how Vandy is described (and nursing in general especially with these automated pharm boxes), but that should be additional consequences, not this nurse avoiding hers.

[bsder]

The hospital that hires the nurse should be responsible for the nurse. Period. Under all circumstances.

The hospital has far too many incentives to play fast and loose and then leave the nurses in the lurch with a system stacked against them. The hospital has far too many incentives to skimp on training and safety. etc.

Should this nurse also have her license looked into? Yeah, it looks like it. And is it up to the hospital to fire her or not? Yes.

However, barring actual proof of premeditation, all charges and fines should land on the hospital--not the nurse.

[rvba]

> She pulled the wrong med, and then injected it and walked out of the room rather than observing for effects

With staff shortages nurses dont have the time for that.

Hire 2x more nurses - so there is 2x more time for each patient.

[Master_Odin]

My GF is a nurse and I've heard her talk about working a number of 12 hour shifts and not having the ability to go to the bathroom, get water, or have lunch, all because of how strapped the unit is and arduous the requirement is to do these things (usually having to leave the unit). I'm honestly shocked we're not hearing more mistakes, and it should be 100% hospital admins on the chopping block for forcing these insane work environments upon nurses while expecting quality patient care.

[BeFlatXIII]

People like you are part of the problem. "It was covered in all kinds of scary warning labels"—just like every other medication in that drawer. Medical professionals are totally blind to alerts given off by their EMRs because everything has a password-protected warning so that the audit logs can say "yes, this physician/nurse read and understood the warning"

[JshWright]

> just like every other medication in that drawer

No, very different from every other med in the drawer. The red cap on the vial is very unusual (reserved for very dangerous meds like this), and the bold printed warning on the top (that you have to look at at least twice while while preparing to administer this medication) is also something used very rarely.

[cyberlurker]

Right, when I first read the summary it didn’t adequately cover how careless the nurse was. It wasn’t just a small mistake.

Edit: I should say that doesn’t mean I think it makes any sense the hospital isn’t liable and jail time for the nurse seems odd