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Once again, we throw a front line caregiver under the bus while our leaders fail to actually LEAD. What ever happened to Just Culture? The tragedy at Vanderbilt.
If you are already familiar with the backstory, skip to 2:44 for my editorial on the arrest of nurse Radonda Vaught. If you disagree with me, leave your thoughts in the comments on the original video!
Links to our earlier videos on this story and to the recent news articles are here.
Full Transcript Below.
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Hey, what’s up ZPac? It’s your boy ZDoggMD, Dr. Zubin Damania. Okay check it out, this is a quick editorial that I really have to get off my chest. I’m not doing it live because I don’t want to be distracted by comments, I just want to give you my thoughts on this case of the Vanderbilt nurse who we’ve talked about before, her name is RaDonda Vaught and the name was just released because she was arrested for reckless homicide and abuse of an impaired adult.
Here was the story and we did a show about this a while back and then a follow up show about just culture and how we can improve safety in the hospital and why we shouldn’t, you know, focus on blame for mistakes but we should focus on process improvement. So this – the basic story is this; nurse Vaught was taking care of Charlene Murphy who was a 75 year old woman who was admitted for a subdural hematoma with some symptoms, she was getting better, presumably this was neuro ICU from what I hear and a lot – a ton of people have messaged me information on the backstory of this privately. And so, she was a help-all nurse that day, had a preceptee with her that was following her.
This was not her, you know, usual patient and she had to go to radiology to take the patient down there for a full-body scan. This was – she didn’t even know where radiology was because the place – this particular place apparently wasn’t on a normal beat and we know this because of the CMS report which I’ve linked to on the website for the original video I did which I’ll put in the links.
Okay, so she goes there, the patient’s claustrophobic, she’s ordered for a Versed for the claustrophobia and sedation in the scan. She goes to the Pyxis, it’s not in the Pyxi – it’s not showing up on the orders in the Pyxis so she doesn’t override, types in VE, a drug comes up, turns out it’s Vecuronium.
She doesn’t go through the “Five Rights” of you know, right patient, right drug, right – you know, right route, all of that, overrides, reconstitutes the Vecuronium presumably because you have to actually reconstitute it and presumably Vecuronium actually says on their paralytic agent but this happened; she administers the drug, they put Ms. Murphey in the scanner and 30 minutes go by, she’s scanned, she’s not monitored, they kind of can barely visualize her, they don’t notice that she’s not breathing. It comes out, they realize she’s not breathing, they call a code, she suffers irreversible brain damage, the family ends up withdrawing support in the unit.
This was a tragedy on every level, it was an entirely preventable error, we’ve talked about already on the show, why and how and who and what and people have weighed in and you know, this should never happen, you know, this was reckless or it wasn’t reckless, it was a systems problem, whatever.
The bottom line is, she made a mistake and the patient died in a terrible way. Vanderbilt then told the patient ultimately that this was a medication error, never told them what medication it was according to the family, they found out a year later. CMS does an investigation, didn’t think that Vanderbilt was actually improving processes around this and threatened to withhold Medicare funding in which point Vanderbilt did some changes that weren’t public, that they haven’t made public.
Now, here’s where it gets really crazy; yesterday, I think it was yesterday, she was arrested and indicted on these charges of reckless homicide and abuse of an impaired adult. Now, it’s been a year. Now, people who know her have already come forth to me and said “this is a nurse I’ve known for years, she’s a great human being, she’s a wonderful nurse, she was respected and liked and she made a mistake that has devastated her, she’s already gone through tons of therapy because of this and there’s a phenomenon called second victim effect where she is a victim as well of this terrible mistake” and whether it should have happened or not, we talked about in the other show.
But the bottom line is, is this a criminal act now? Is arresting her and putting her in prison and making her go through trial a good way to improve safety and hold people accountable in medicine in the future? Does the family want it? By the way, the answer to that is, it seems like not. They have gone on record and said that if Charlene Murphy were alive today, she would have forgiven this nurse and would have been so sad that there are now two victims and two lives destroyed and two families destroyed because of this. And there has been on the back end, an outpouring of support for this nurse.
Well, here is what I think; this is a shameful act to put this woman who is already paying the price for her mistake in prison. If you are gonna do that, you should put all of the administrators at Vanderbilt who were overseeing her, who were overseeing safety, who were responsible for communicating with CMS and with the patient, they should all go to jail! How is it that we throw our frontline healthcare providers under the bus for a mistake that was partially contributed to by a system that allows a patient to be unmonitored in radiology, that allows a Pyxis to dispense you know, Vecuronium and be with…
I mean, there’s so many failures you can point to, including the human failure right? From nurse Vaught, that including that but how can – if you put this woman in jail, this is gonna set a precedent that is gonna destroy what little morale we have left on the front lines.
Do you remember we did a show about Dr. Bawa-Garba and she was a pediatric resident in Great Britain, was also arrested and charged criminally with you know, negligent homicide, manslaughter, whatever it was because of a mistake she made where she missed Sepsis on a child she was caring for in the hospital as a resident, with a ton of other patients, a mistake any of us could have made and she was arrested and criminally charged. And we talked about how inappropriate that was.
Is this different? In a “Just Culture” environment, you would look all the problem; was there malice, was their intent? No. Was there may be reckless behavior in terms of missing you know, the five rights and all the ways you dispense medication and looking and monitoring and all that? Maybe. But does that mean that you go to jail for that? Who here hasn’t made a mistake that’s harmed a patient who takes care of patients all the time? I’m not raising my hand, I’ve made those mistakes.
If I was afraid I was going to go to jail, what do you think will happen to reporting of errors from now on? They are gonna be even more covered up than they already are. What we need is radical transparency, what we need is a system that helps to improve itself when we find errors like this and make sure they never happen again, we need accountability from our leadership, our leadership to make sure that systems improvement happen and that radical transparency occurs.
I have heard from this nurse’s friends that she was told she wasn’t going to be fired then she was marched in like a month later and told bye-bye. Hey, there’s the therapists office. OK? And saying what you will about whether she should have been fired or not, this is just terrible terrible systems architecture and management. And until I learn more about how Vanderbilt is handling this, they have thrown this nurse under the bus until proven otherwise. OK? That’s my take.
So, here’s what I say to RaDonda Vaught, okay? I support you, I don’t think you should be in prison, I think you have suffered enough, I think the people who are responsible for changing systems and architecture in that hospital need to be held accountable and need to improve the systems, I need you ZPac to share this, to leave your comment. If you disagree with me, cool. Come at me in the comments, OK? I didn’t do this live because I didn’t want to go at you right now but I’ll go at you in the comments, come at me and I want Redonda to know that there’s a good part of the ZPac that really supports her in recovering.
By the way, the Tennessee Board of Nursing did not rescind her license; they looked at the case, that’s my understanding of it, okay. This is a civil case; if the family wanted to sue it all up, that’s a different subject. This is not a criminal case and if we start treating our frontline nurses and our frontline staff who are suffering all around the country as criminals, when patients are punching at them and everybody’s pushing on them, you will break this system and we will not stand for it. That is it! So, I hope you’re with me on this, if you’re not, leave a rational response why you think I’m wrong or why this woman should go to jail for her mistake.
All right guys, hit share and we’re out.