[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).