HUGE thanks to the team over at Dr. Levin Jubbal's channel for making this video possible and providing me with ALL of the details and research to make this video. Go check out his video as well! kzfaq.info/get/bejne/jr1lorB0u8iZg2Q.html

I'v been a nurse for 17 years, and the best thing that ever happened to me was exiting this profession during COVID19, I can say this with absolute certainty, because I am no longer on blood pressure medications, I sleep good at night, my stress level is low, etc...

It’s nice to hear from the point of a true medical professional instead of the true crimers. Coming from healthcare administration, I am confused as to why the nurse manager didn’t get charged somehow for not reporting

As a retired Rn of 44 years this is terrifying. Yes mistakes happen and I’ve carried my own malpractice insurance for decades knowing that my employers would NEVER have my back, no matter how loyal you are/were with them. Telling the truth about errors is paramount. The good people understand.🙏

I'm a retired nurse of 25 years experience in Canada. This nurse made a bad medication error, but it seems to me that there was a problem with the system. Why was this high level sedative medication so easily accessible, why wasn't there a 2 nurse sign off, or an administration checklist or protocol? This sets up a "trap" for any nurse who is having a bad day. If nurses can be prosecuted and go to jail for errors, nobody will want to do their job anymore. Stay in a job where an error does not send you to jail.

She didn't work in nuclear medicine or radiology. She was called down to the unit to help a patient who was from her original unit, though not her own patient (most units don't give Versed outside of OR or radiology). Next, the hospital was changing to a new system (Epic) and nurse's had been having to override medications a lot in that time. Even if not, there is often a delay in when a med is ordered and when it shows in the pyxis which is why it didn't show up in the patient's name. However, she didn't seem to know the generic name which is how the meds are found in the med dispensing system. Versed is a brand name and she searched by it. She obviously didn't closely look at the med however and so definitely negligent here. Next when she got down to radiology (where she didn't work), there was no scanner to scan the med and the patient. She did attempt to find one but time was running out and supposedly radiology was threatening to send the patient back up stairs without the test. It was the day after Christmas and the patient was anxious to get home to her family. So, big mistake, she gave the med without scanning the patient which would have alerted that the med wasn't on their med list. Lastly, she had a student or preceptee with her which added distraction. I'm not excusing what happened, but the hospital did not provide the tools for her to do her job as well as possible. Per her there was no warning that came up and her preceptee agreed to that. They were also being asked to go to the ER to help there and radiology said there was no need to stay and monitor and so she left. I'm not saying it's OK that this happened, but charging her and not addressing the systemic issues that helped create it, make it easy for this to just happen again.

Turns out the DA has ties to Vanderbilt along with the Board of Nursing. When Vandy found out they were going to be investigated by CMS, they needed a scapegoat. It’s the biggest conflict of interest but those that would otherwise have overseen that, are involved. Later we found out that her defense should have caught something like this but turns out he also contributed to the DA’s campaign. It’s a whole mess.

I’m a nurse of 30 years and NO hospital can pay me enough to go back to bedside nursing! I have been on the other side for the past 15 years and it’s very disheartening especially if you stand up for your staff! What this case did is to say nurse are not valued and are easily replaced because schools are popping them out every 6 to 18 months. This is a very very bad standard for the future of bedside nursing. I would not encourage any of my daughters or granddaughters into hospital base nursing!! My heart broke for this young lady who was used as a scapegoat 😤

It's heartbreaking to hear. As a nurse, I think the only way to avoid mistakes is to have a 1: 1 or 1: 2 ratio in any department.

Was she negligent? Absolutely. Should this be a criminal case? No. Vanderbilt needs to be reprimanded for this.

As a medical student, I am concerned that this could happen to any of us since we are prone to make mistakes with long-hour shifts, especially during residency. Imagine long hours of study and years of training to be placed in court as a criminal is something I can not even comprehend.

Hey there are some things you got wrong/may not know. 1)she wasn’t specifically a radiology/nm nurse. She was a ICU nurse who came down to admin the medication as a favor to the patients assigned nurse that day. 2) There also was no scanner in the NM department and that part of radiology. This means she could scan the patient and the drug. 3) At the time of the incident the policy at Vanderbilt was if only versed was being given no monitoring was necessary. 4) She pulled that med from the upstairs med drawer from the ICU. 5) The doctor who determined COD stated it was a brain bleed. Indicating a cover up attempt (on behalf of himself and Vandy likely) and apparently he had done it before 5)The reason why she was able to override the med was because Vanderbilt at the time was switching EHR systems and was having issues with meds not being able to be pulled despite it being ordered and in the EHR chart so nurses were having to override meds until it could get fixed (and this is what they were specifically told to do; they were told until it gets fixed they needed to override if necessary). 6) That DA has ties to Vanderbilt by the way. He is up for re-election too and Vanderbilt has a lot of sway. Therefore by charging and convicting it clears Vanderbilt name and then they will still support that DA. The DA also has ties to the nursing board.

I am a Registered Nurse myself, this could happen to anyone of us. I watch the story in detail, my heart goes out to her. God is in the detail, it's great to see so many people supporting her

This is terrifying! As a nurse, I have made mistakes and self reported. When I worked in the hospital, if needed I could be assigned extra patients, above the set nurse to patient ratio, and I could not refuse. In addition, I couldn’t walk out or I could be charged with abandonment. Why isn’t the administration being held accountable? We are human. We all make mistakes and now we need to worry about going to prison too.

As a student in healthcare, this story is terrifying. Thank you for speaking out and raising all these relevant questions

Mistakes have been made in the healthcare system throughout history. Blaming and sending a nurse to prison, taking her license, etc., is insane!

As a nurse of 7 years, Dr C, I want to thank you for the beautiful speech!!!! Totally agree. I’m still a baby in comparison to the OGs in this field but it’s scary for anyone working in healthcare 👍👍👍👍👍

Just tried pulling Vecuronium from our Pyxis and yup, there were warnings and big orange labels around the vial and cubbie, but no two-nurse verifications, didn’t need to override it (in the ED albeit not in the orders) just shows how the system really has the potential to allow these errors to happen on possibly your worst day ever

I was a med surg bedside nurse for about 3 years. I already had intentions of quiting due to how we were being treated but Radonda's case proved to me that I made the right decision in leaving nursing. It was truly the best decision I ever made. Which is sad because it just shows where Healthcare is headed..

As an anesthesiologist, I can tell you this was not a simple med error, (not going to go into the fact that elderly patients, and especially Neuro critical care patients who have SDH should NOT EVER GET BENZOS) This nurse put forth an enormous effort to kill this patient. Forcing her to reconstitute a drug would give anyone pause, overriding 5 paralyzing warnings in the pyxis, not reading med label. In fact while reconstituting she would have had to read the vial where it says vecuronium and paralyzing agent to see how much saline is needed to reconstitute. Idk what went on in her head during this but if criminically negligent homicide exists this is it. She took 100 steps OUT OF HER WAY to kill this patient. If it was a liquid maybe people could give the benefit of the doubt of this being a med error but no way in hell can you say this was a simple med error when she had to reconstitute.

I’m all for forgiving mistakes, but I also work in emergency medicine and I can tell you there’s a huge difference between versed and vec. In the ERs I’ve worked in paralytics are not easily accessible; you can get them but there are measures to prevent anybody from getting into them by accident. This is probably why.

All nurses need to refuse to "over ride" the med dispenser. The hospital needs to have enough pharmacists on hand to make sure those orders are processed timely and correctly. Further those medications should only be referred to by their generic names. Looking up by a brand name should be a separate lookup. When these agents are administered it should be understood that the administering nurse is now required to monitor for some set period of time.. They are not to by punished for not doing other things, like they usually are. Lastly, all nurses should immediately start invoking the 5th amendment when questioned about past actions. Their replies should simply by, "All actions for a patient are charted, please check it for answers to your questions. I'm invoking my fifth amendment right's with regards to additional questions."

I appreciate your analysis of the situation. There is so much more to the situation than what you discussed here. I 100% agree with your opinion though. During this time at Vanderbilt they were in a transition phase from their previous EMR to Epic. There was an issue with medications crossing over from the EMR to the Pyxis/omnicell. When the physician entered Versed into the EMR it did not cross over and show up in the Omnicell. This was a reoccurring issue with all patients at Vanderbilt during this time. There were major systemic failures at the hospital. This one patient had over 20 to 30 overrides under her name for medications during her stay at the hospital and she had only been there a few days. Also the prosecution liked to point out that she did not scan the patient & the medication before administration which was hospital policy. However they failed to mention that the radiology department did not have a computer with a scanner installed. There was no access to one. Why would Vanderbilt install a medication Omni cell in the radiology department but never install a scanner for medication administration? I have carried medication into a patient’s room before and the only thing that stopped me from administering it was the fact that when I scanned the patient and then the medication I was alerted that that medication was not on that patients EMAR. She was unable to do this. Being a Nashville nurse I have followed this case closely and I have friends who worked at Vanderbilt during the time that this happened. They have told me that the transition to the new EMR epic was a complete nightmare. They say that nothing was working correctly at that time. I also know a nurse who knew Radonda and he says that she was a wonderful nurse and when she realized her medication error she immediately spoke up and told everyone and did not hide anything. This entire situation is horrible and there is still so much more involved in this situation. The district attorney, Glenn Funk, who chose to prosecute her is also a Vanderbilt law professor. Something does not sound right about that since this incident happened at Vanderbilt University. Radonda’s sentencing hearing is May 13th in Nashville and I have heard that there are nurses from all over the country flying in to be there. I’m interested to see if there will be a few hundred there or a few thousand. There is also a change.org petition that has almost 200,000 signatures on it asking for clemency for her. www.change.org/p/grant-radonda-vaught-clemency

Death by an injection of Vecuronium must be one of the worst ways to day. Being completely paralized and sufocate while completely awake must be horrifying.

Couldn’t agree more. Why wouldn’t Vanderbilt/ whoever didn’t report the error get prosecuted?

I am glad I am retiring soon, nursing has changed and not for the best! I have worked in a hospital since I was 16 and now I am 60 and the hospitals are never held responsible, it is always the nurses!! Thanks for speaking truth!

I'm a nurse. I've been in home care for a few years and was considering going back into hospital nursing. I saw this case and was immediately like, oh, hell, no, never again.

Why didn’t she know the difference in the medication if she’s given it so many time? Why didn’t she see the warming on top of the vial that she put the needle in? Why she should be held accountable is because she took a life that she can’t give back, loosing her license isn’t good enough. There should be others being held accountable as well, but she definitely needs to be. It is a mistake but it’s also a life. If it was my family member, sorry would not be good enough. Her losing a job would not be good enough. My aunts, sister, cousins, sister in laws, mother in law are all nurses, two doctors, this is something I hope they pay attention to. Oops is not the answer

As a senior nursing student, this legitimately terrifies me.

This saddens me on so many levels. My heart goes out to this nurse, because you’re right, it could have been any of us. She is being scapegoated to protect the reputation of the medical facility. She followed protocol in reporting the error; she was transparent in admitting the error. All of the “why’s” rou raise are valid, but will never see the light of day. If there was anything I learned in my 41 year nursing career (thankfully retired now), is the “trickle down effect” of blame.ultimately, it’s usually nursing who gets thrown under the bus to save face for the institution. Would I ever encourage anyone who’s considering a career in nursing? In this day and age, NO. Until nurses are recognized for their value and worth, and paid accordingly, jut NO. As much as I loved the majority of my career, the last 5 years or so were gut-wrenching, soul-sapping, emotionally draining and physically exhausting, abject misery. I would never want anyone to feel that way. Thankfully, the good times and wonderful memories and people will be what I hold dearest.

As a retired nurse I completely agree with you. Makes me glad I’m not a practicing nurse. This nurse for sure did not intend to kill this patient. I don’t I understand how she could over ride the drug machine. I know of no way I could have done that

I am completely confused by anyone thinking that her actions somehow remover her culpability. It doesn't matter if the system failed following her error, that has nothing to do with her failure to ensure she administered the proper drug. Yes, she was honest. Yes, she reported her error. That doesn't change the significance of the error, or HOW it should be handled once law enforcement become involved. If anything, one could argue that once she observed the hospital wasn't going to report her negligence to the authorities, she should have reported her actions to the police herself. What she did is no different than a police officer accidentally using their firearm instead of their taser. Once you remove the actual tools used, it comes down to the same base thing. The trained professional knew the proper procedure, knew the importance of following the rules and regulations regarding their actions, and failed to follow those procedures. That is exactly what negligence IS. It is an accident that was caused by not following the proper rules and regulations... (apologies, I am Autistic and the previous sentence doesn't... FEEL right... so if it is confusing to anyone else, understand it is because I could not come up with better words to define what I feel). All the above brings us to the most important issue with what you were saying about not punishing medical practitioner's with making mistakes because then they won't report them. That... that is a VERY dangerous statement. The way I understood it is you were saying that there's a difference between a mistake and negligence... but that only works in one direction. One could always write a sentence and replace 'negligence' with 'mistake' and you would never have to worry about accidentally putting an innocent person in prison. If you write the same sentence and MEAN mistake, but use negligence, then someone innocent can go to prison. Reporting of the action itself though is not what defines negligence vs mistake. What she did was negligent. End of story. She was using a drug that she clearly KNEW how to use. She KNEW that she was supposed to read the labels. She KNEW she was supposed to monitor the patient. All these RESPONSIBILITIES were ignored which made her mistake, negligent. The exact same reason an accidental discharge is NEVER an accident and always NEGLIGENCE (unless the firearm itself broke in some way that allowed it to to fire without the operator). So as sad as it is... she deserved to go to jail. Her negligence led to a person dying and she is responsible for that. This is no different than expecting police to be held accountable for their actions, whether it was an accident or intentional.

Let’s just hope Vandy has an excellent communications and HR department for the recruitment and retention of nurses! Well articulated and objective commentary. Thank you. The implications of this precedent are indeed profound because not only has she lost her ability to practice nursing but she has lost a substantial ability to have normalcy and livelihood. The charges against her are a class E felony. As a felon, it will be incredibly difficult to obtain suitable employment and housing. The US has a deplorable recidivism rate so I am unsure of the potential psychological, social, and ethical implications this will have for the trajectory of her life. This integration and ever pervasive social ostracism of “cancel culture” will only further deter transparency of future nurses, health care providers, and physicians. Ultimately resulting in increased prevalence of sentinel events, health care worker job turnover, and patient death.

It sounds like the hospital admin leaked the info for the purpose of protecting their name and used her as the lowest hanging fruit as the scapegoat. Sounds like CYA to me

I remember at my first job out of school. A nurse injected Milk of Magnesia into a patient. After the patient died, she was sued along with the hospital, the M.D. and anyone else even tangentially related to the case. The nurse then sued her nursing school for never specifically teaching her that you should not inject oral medications into a patient. The family got a huge payout and she had her license revoked and the nursing school and M.D. were absolved of any responsibility. The hospital, on the other hand, settled out of court.

AMEN! from a long time healthcare professional! Takes me back to my very early days as an RN - new grad- horrible staffing- being put in charge of whole floors - handed a med key and cart - and off we went!

When there is a trillion things going around you, everyone calling you, things get out of hands really quick. I quit bedside. I quit been a nurse for that reason. I almost committed the same mistake, and that’s when I knew the system is failing us and the patients.

Conscious, well aware, and completely unable to breath… incredibly tragic

You said you didn't want to diminish concern for the patient but that is precisely what you did. The patient received all of 5 seconds of concern in this narrative.

I am a retired nurse also this is terrible she was made the scapegoat in this situation very frightening! Doesn't surprise me about the lack of support from the facility most don't care about staff or conditions and they wonder why they are so short staffed!! I miss my patients the doctors and fellow nurses but don't miss what medicine has become. I served my patients for 40 yrs. My last 3 were horrible in terms of stress and understaffed. Its a shame. God bless her heart my prayers out to her and her family. And to the patients family. Very scary.

In an otherwise imperfect world, health care workers are expected to be perfect. Mistakes can happen at anytime and even the brightest and most experienced professional can and will err. People need to understand that their doctors/nurses/providers are human too. If you imagine this scenario as if the nurse's job is reduced to exclusively drawing a medication, preparing it and giving it to the patient, you are not considering that very likely she was also on the phone, charting, taking or giving report, getting called by multiple providers about other patients, procedures, orders, delays in labs, delays in medications, family members questions, transport, documentation, consents, rapid responses, pharmacy notifications... the list goes on and on and on. And this is true from the moment you clock in until the very last second of the unpaid extra hours you have to work to get everything done before going home. That is what we all mean when we say it is a "systemic" issue.

I remember when I was in nursing school my teachers would tell us students stories about these nurses that were prosecuted for things like this and I used to think that they were kind of fear mongering and scare us into second guessing our decisions to become nurses ourselves. Now I realize how the system sets us up for failure. I can only speak for myself but I think that most of us go into the medical field with good intentions. We just want to care for our patients and see them get better and happy but with the way how things are it's like we are expected to make no errors and be perfect which is unrealistic because nothing will ever be. Even if we were to be replaced with robots/machines, they aren't perfect because they are as smart as whoever designed them which ultimately is us humans and we make errors because it's in our nature. It's crazy how one slip-up can turn your life upside down and end your whole career and pretty much your life. All the hard work you put in to become a nurse is down the drain.

Wow😮 I’m a retired Certified Pharmacy Technician with 15 yrs experience I worked briefly with a couple of new PT’s that did that! They couldn’t find the correct pills on the shelf,so they did what this nurse did!They pulled the wrong drug! They did it on purpose. Thank god they didn’t work there more than a few days! They couldn’t find the drug they needed so they picked the drug next to it. Thankfully we had a computer over ride system,where you needed to scan the script label then scan the medication bottle. If it matched up it took you to the next verification screen on the computer. You then filled the script and it went through 2 more checks by the pharmacist.I loved my job,took an early retirement when the pharmacy closed

I'm a pharmacist of 5 years and was going through an abusive relationship and severe PTSD while working. Anything can happen anytime and this is incredibly scary for any HCP! I have a lot of compassion for this woman

Thanks for calling out the REAL PROBLEMS with how nurses are made into scapegoats for hospitals, which are the ones responsible for their safety standards, or lack thereof! Kudos to you for speaking out!

This is exactly one of the reasons I left hospital nursing years ago and have been working in the Home Health Care setting. You will be individually "Hung out to dry" by hospital administration and as mentioned, nothing will be done about a systemic problem.

She really missed the 5 W's of medication administration. I am an RN of 25 yrs and my husband had a car wreck that broke 22 bones and left him with a closed head injury. His pelvis was shattered which left him with an exterior fixator across his pelvis. He was non-ambulatory for about 4-5 months. He was also a Type II Diabetic. During his rehab stay I had asked several times that he not be given sliding scale insulin since he was on a 24 hour acting insulin. I was afraid it would lower his blood sugar too much. Well the doctor didn't listen and continued with sliding scale. One morning while I was there the nurse came in and administered the sliding scale. My husband's blood sugar went down to 13. He had zero metabolitic activity. EMT's got him back and when he got out of the hospital and back to rehab we had a come to Jesus meeting. I didn't sue them but I should have. Idiots.

This blows my mind. You raise very cogent points. I'm still in my final year of RNs but I don't think this would be possible in Australia. All dangerous drugs and all IV meds are independently checked by two nurses (preparing and administering). ALL meds in paediatrics are double nurse checked as well. I guess this case is a reason why that's a good practice.

I will never forget how hospital administrators were able to get the Covid-19 vaccine immediately after it was distributed to our hospital, while doctors and nurses had to wait. Insurance companies and hospital administrators are the main problem in the healthcare system.

Vanderbilt was going to lose some federal funding when this was discovered and the DA is related to the head of Vanderbilt. This nurse was used as a scapegoat! Not to mention Vanderbilt has had SEVERAL issues over the years! How can we help fix this? I am not in healthcare but even I know this is horrible for healthcare! I hope she’s appealing and I hope there is a way the relationship between the DA and head of Vanderbilt is investigated!

I’m super glad she got criminally prosecuted her. How are you going to inject something into someone’s body without even reading the bottle and I feel really disturbing that so many nurses support and think it was fine.

Great points, Dr. C! As a seasoned RN, and nursing professor, I agree with everyone you said. I've given both those meds many times. The public does not realize that likely only 10% of all medical errors are ever reported. Most errors are minor, cause little to no harm, and frankly, filling out the paperwork takes a lot of time. The significant errors are often only dealt with when people are caught, are honest/take responsibility (like Rhonda), or hospitals are forced to deal with them (but look at how Vanderbilt hid the actual cause of death). The fear of getting in trouble, regardless if the organization has a "Just Culture" philosophy, is always real. The other real shocker is the HUGE under-reporting of "near misses"--I'm guessing more like 0.01%! Again, if "nothing" happened, who has time to report it? These are the realities of health care, and Rhonda's case (for all the reasons mentioned) will make it even less transparent.

I understand this work is stressful but let's not speak on someone else's lack of following protocol. Not following the guidelines in place no matter how busy it is, is the best way to make sure something bad happens. I heard it was not a busy day and she was training someone to not follow protocol. I'm not trying to belittle the highly stressful environment but this isn't a delivery gone wrong so no matter how stressful it is you still have to do the right thing. I hope all medical personnel learned something from this. I learned from now on to ask more questions and to ask nurses and doctors how their day is going, make an attempt to make them smile, and talk to me about any meds they are giving me. You won't kill me because you are stressed.

Okay folks, let me try this another way, since many of you are still hell bent on taking up for this person. Your 16 year old child makes a few calls to friends, gets on Internet and hears there is a big party going on. She ask if she can go and after hearing it's a party of kids and young adults that she doesn't usually hang out with, you make the decision it's not a good idea and say " no " Your child sneaks out anyway and doesn't return until the next afternoon. Reason she gives is " mom I had a couple drinks and knew you wouldn't want me driving home" What a great kid. She made a good decision not to drive intoxicated. But you take her phone, and computer away anyway. She crys, tells you its unfair and slams her bedroom door in your face. You open it and tell her, you weren't finished. She is also grounded for 2 months except for going to school. Her reply, " but mom I said I was sorry." You want her to understand, there are consequences to not following your orders. She didn't know the kids. There were 21 and 25 year old young adults there, no parents and you had no idea where she was all night as you sat up and worried. Harsh punishment? Or good parenting? Sometimes saying " sorry " isn't enough. Same with the Nurse. Was it a mistake? As a Nurse, yes I've seen a few people make mistakes. Yes they are sorry and they didn't mean to cause harm to anyone. It's like running a red light accidentally. You either didn't see it or tried to beat it. You crash into a car and kill the family. You didn't mean to kill anyone but your reckless, careless mistake did kill a family. That was one red light. You probably will go to jail. The Nurse ran 15 to 18 red lights ( safety measures in place ) How many red lights were needed before she paid attention to one and stopped? She chose to over ride every safety measure. Not even look at the med label and warnings, then left a patient alone on 1st floor and went back to 6th floor. By her own admission she wasn't busy or rushed. Then why didn't you monitor the patient you just sedated? Careless, negligent and reckless. The patient, Charlene Murphy trusted the Nurse to give good care. Instead she died a horrific and terrifying death. Her body couldn't move. Yet she knew what was going on. Unable to call for help. This death was preventable. Not one Nurse I know has made these many careless mistakes. They usually catch the error by following safety measures. She didn't chart she gave the med. In fact she didn't admit her mistakes until a second Nurse confronted her with evidense. There are a lot of good Nurses who follow protocols, safety measures and rules. Then there are others. As a Nurse your priority is the care and safety of your patient. Because folks, without patients, we aren't needed. You can argue lots of people make mistakes. I'm telling you I've seen very few errors from competent, skilled Nurses. They give 100 %, they sacrificed and studied long hours going through school ( others barely got by) The good Nurses check, recheck, and check again. They are there for their patients for more than a job, they are there for their patients regardless of the patients finances, race or status. Jail time might make people and Nurses realize they have a patient's precious life in their hands and should be more responsible than to run red light after red light. Shame on you for not wanting the highest accountability from this Nurse. She took too many short cuts. Who knows if she did it before and just wasn't caught. She almost didn't get caught this time. Don't let another innocent patient be harmed or die in vain. Stand up, speak up for changes. But to stand up for this negligent Nurse won't solve anything but send a message to others like her, it's okay if you kill a patient, you won't do jail time. It's okay you aren't competent or skilled or even care for your patients safety. There should be laws in place to protect patients from Medical Staff such as Rodonda Vaught. And we all have worked with them, in every field of work. Just wondering if a drug test was done immediately after the event happened? As for the hospital. They too are guilty. They didn't report the med error because they said they didn't realize it was neglect. BS. You are covering your ass. They didn't report it to their accrediting agency either. Joint Commission. They didn't even report the non natural death to the medical examiner. As for the family forgiving the Nurse. They were paid off to keep quiet. Yet, some family that were notified had a different point of view. They took video of mom as she was having seizures while she died. Hmmm, the lawsuits may not be over yet. Think about what really happened here folks. It wasn't a simple error. But yes we do need changes. Put your effort in to making changes to protect patients. If not, med error Nurse may come knocking at your door or your grandchilds door the next time you go to the hospital. Don't let patients have died needlessly in vain.

Dr. Cellini - I have the utmost respect for you, thank for sharing the reality of this entire situation. You have put your professional neck on the line here. I am a long term quadriplegic (SCI for 40 years from a MVA at age 15) who has recently required multiple CT and MRIs due to a pressure sore. I still work and try to manage a general life. I'm grateful that I don't require sedation for any scans but for sure, this nurse certainly didn't have bad intentions. It's a rough call though as she made the wrong decision and I'm glad that I wasn't the recipient. Still, somehow the blame has to be shared with the larger system for sure, but by the time it hits the higher ups, it's too late and we patients would be gone. The simple problem was with the med delivery system - that poor nurse should never have had any 'V' medication option and it should have been questioned at the time of administration. I see both sides - my hope is to not blame but to just find a solution to rectify these challenges.

Could this have happened to anyone though? I would hope the people responsible for the patients health are not this careless. She disregarded multiple red flags that seemed like pretty big differences between the medicine she gave and the medicine she needed to give.

These types of videos of yours really helps general public to get sensitised with matters related to healthcare. Its good that people like you can bring some sense into such delicate topics.

PA type here. What a ridiculous ruling. -Vaught should lose her license, but negligent homicide? For context people who leave babies in hot cars get convicted of negligent homicide. -There were lots of systemic factors that led to this mistake. -Mistakes happen unfortunately. -Not reporting/covering up mistakes is unforgivable. It prevents a system of from improving itself. -We need Nurses. And we need those Nurses to tell us if a mistake was made. This ruling will make both of these things more difficult.

"So instead she used the override function and found a similar drug that started with 'Ve.'" As Mark Twain said, the difference between the right word and wrong word is the difference between lightning and lightning bug.

I worked in Transfusion medicine and we have so many checks and balances for the administration of blood products. I’m surprised that similar processes are not followed for medications.

As a nurse this video is much appreciated. The way this situation was handled was downright criminal and the verdict was definitely unjust, can this be appealed?

i've been a nurse for close to 5 years, and now I am in medical school. i can see both sides of this, however I can't ignore the facts. fact one: the nurse is to blame. there's no question on that, she overode the system, and pulled the wrong med. any number of excuses can be made for why, but ultimately there is a process called the 8 rights, 10 rights, 12 rights (they keep adding more) on medication administration. she didn't follow them. she went outside her scope of practice and killed someone. fact two: the hospital covered it up. this is the more scary part of this whole thing, because anyone can look up medical error stats, and I'll tell you I've seen numbers averaging anywhere from 100k, to 300k deaths per year attributed to medical errors. activists want to ban guns because 20-40k deaths per year are gun related (mostly suicides) but NO ONE is saying we should ban hospitals. the truth is, this story is scary because shit like this happens ALL THE TIME, we just never hear about it because the story is never publicized and no one is ever held accountable. healthcare is a joke, we as an industry tell the consumer, and don't get me wrong you are a consumer here; no facility exists to help you because it's the right thing over making a profit, if you don't believe me ask them why they automatically run sepsis bundles on one criteria when the standard is two, or why it takes 5-10 xrays to diagnose a fracture when they could probably do it in 1-2, why do 85 year olds need new hips and knees made of titanium when they have chronic CHF and/or renal failure and wouldn't get up to dance a jig even if it were 1956 again? why was this woman with a hemtoma going for a pet scan when she was due to be released anyway? it's billing. docs are often trapped in this broken system too, because they can't pay their loans if they don't make money, and hospitals won't pay out their contracts if they aren't generating enough revenue for the dept/facility. we tell you we got you, we'll take care of you, etc; but the truth is there are many dumb docs, and even dumber nurses being rolled off the assembly line to fill the demand of facilities. the real reason this story is getting so much attention; hopefully in my opinion is that some of these hospital executives will start getting charged with crimes too. mega corp healthcare facilities may also face harsher fines too. the only way to really change things, to really make any of those corporate robots care, is to hit them where it hurts; their wallets. or put them in jail with bubba.

I refuse to work in a hospital at this point. I’ll take my nursing license literally anywhere else.

This is why I quit nursing. I was overwhelmed by overwork and was super prone to medication errors. My supervisors didn't care and the bottom line was profits for the company vs real genuine Healthcare.

The issue is that they're not actually doing anything to prevent this from happening in the future, they're making the issues that are already in place an even bigger problem. The exact issues that lead up to being a contributing factor in this case were not resolved, acknowledged or improved, and these issues will continue.

I think healthcare workers in general are way too comfortable with errors happening and going to lunch. Everything is overridden by everyone. We need to be a little more terrified when we are on the clock. These are people's lives. Don't make excuses, we have to get better. Some things can be avoided. This was one of those times

I have been a nurse for 15 years. Regardless of policies, red flags, lack of monitor, no scanner, switching to new EMR, etc.; the issue is gross negligence and a human life was taken prematurely. I have 1 simple comment for everyone: Where was her common sense?

Nurse Liz did a great job on the nursing perspective of this case. Physicians and providers generate income, but nurses are just a necessary expense. RNs and LPNs are more expendable and make easier scapegoats. I don't disagree that she made a horrible mistake, but to think that a nurse could become a felon for making an honest mistake is terrifying.

Thank you for this video! This situation is terrifying and heartbreaking- I pray she doesn’t get jail time. I have some comments and welcome debate - 36 year nurse here with experience as a charge nurse as well as a nurse manager on a 40 bed inpatient BH unit. I’ve been obsessed with this case as are so many health professionals out there. I watched literally hours of this trial as well as listened to her interview with the board of nursing and her interview with the TBI. I think she has suffered enough and will be very sad for her if she serves jail time. All of that being said here is my take away: 1. Being honest is good, but this woman talked way way way too much. There’s such a thing as not hiding anything but she would NOT be quiet. She WAIVED her Miranda rights and did not have a lawyer with her and just talked and talked and talked, nailing herself to the cross. A lawyer in another video said he felt this case would have NEVER gone to trial if she had obtained a lawyer and did not speak to ANYONE until she secured one. She basically ruined any chance for the defense lawyer: she had the choice to precept that day: she welcomed it. Were you under staffed? “ no we were fine.” Were you stressed? “ no I was fine.” Do you feel unsupported? “ no I work with a great staff…” do you feel they need another float nurse on the unit? “No, one nurse can handle it….” And so it went, with no lawyer present and a signature waiving her Miranda rights she talked and talked and talked over an hour, telling them she caused it, etc etc. “I should have been more careful, I shouldn’t have made the overrides, I should have scanned the meds…”. several people including the lawyer in the video I watched said that we need to keep our mouths ZIPPED until we get a lawyer. Our mantra should be: “I wish to remain silent, I want a lawyer, I wish to remain silent, I want a lawyer…” period. Nothing else. After the interview with the woman who works with Medicaid fraud and who read her the Miranda rights prior to the interview the nurse Radonda asked, “ now what do you do again? What is your role? I guess I need to get a lawyer?” Last point: the interesting thing I noticed as both a charge nurse and a nurse manager- complacency leads you down the road to danger. Most incidents happened when there was more than enough staff present. We let our guard down, and in came the errors. You need that tiny nervous edge to maintain safety- just my opinion

Dr. Cellini, thanks for covering this topic. As an RN myself, I was curious to know your perspective and opinion, and I couldn't agree with you more. Well done.

What terrifies patients is that this could be any of us.

As a TRUCK DRIVER, I will sit this one out... Naw Nevermind...One fatal mistake out here and we are done. So many can be wrapped around a fatal error, but ultimately the accident is laid in the drivers hand because he or she had the final decision. Brokers are pushy asf and can really screw you up if they get mad with you. Pushy brokers, demanding customers and Jenks on the roads. All the questions you just asked at the end, I can relate to trucking. They rip your license up to shreds, so why prosecute? Because someone died.... Same goes for the nurse... Am I missing something?

Agree with everything you said. This should be terrifying to medical providers.

I don’t understand why everyone is standing up for her. I’m a nurse. We’ve all worked with those nurses who are terrible. They don’t give a crap about their patients. She obviously didn’t have any idea what she was doing. That is scary. What if that was your family member?

I have recently graduated from nursing school and this terrifies me. In school and on rotations I have learned that when administering medication the nurse suppose to do three checks against the doctor's order or the MAR. i.e when at the medicine cabinet, checking when drawing up the meds and at the patient's bedside. These are standard protocols to avoid medication errors. It doesn't matter how respected as a nurse you are any mistake can be for the worse as you can see in this case. Therefore, you always have to look out for yourself and be careful where you put your signature. Question physician's orders because even though it is the doctor that is prescribing the meds you are the one giving it thus you will be held accountable and responsible.

This trial really resonates with me. As a critical care RN in a Neuroscience unit, we have patients who get pet scans all the time in presence of an hematoma because hematoma’s can be a result of masses. There are many times the MDs give patients medication to relax them for this imaging and other imaging for that matter. I agree with you, having a paralytic that can be overridden is scary. This does make me want to rethink being a nurse

She was grossly negligent and it lead to the untimely death of a vulnerable adult in her care.

I understand what was said and what some of y'all are saying however, someone died on her watch, due to her mistake. SOMEONE DIED. Consequences must be given.

After working as a bedside nurse for 3 years I have accepted a position away from the bedside. I saw absolutely no light at the end of the tunnel, as a matter of fact it is becoming dimmer and dimmer for nurses.

Thank you for speaking out against this case. As a future PA this is pretty scary. I certainly won't chose to work at Vanderbilt or even in Tennessee, but there are hospitals all over the country that have questionable practices and policies. Are there any databases where practicing providers can list some of the questionable practices at their hospital ie patient to provider ratio? This would help those of us entering the field to chose a facility that will support us as we are starting out.

If she was a general nurse helping out in several areas she should have been even more careful than usual. At the end of the day, this nurse is being held accountable for her reckless actions just like anyone outside a hospital would be. This doesn't sound like an emergency situation where her mental abilities were taxed, her job was to read the label and administer only what was prescribed. Others should've been held accountable as well.

Of all the videos I have watched on this case, yours is the most informative and detailed. Thank you!

Being overworked doesn't explain a nurse overriding a medication system. She did not mistakenly give the wrong medicine. That would have been a different scenario. She knowingly gave the wrong medication by overriding the system. Before giving the medicine, she should have double checked with the doctor. I know some of the doctors are hauty and hard to talk to but patient safety should be top priority.

Thank you for bringing all of this to light. I totally agree that many others should have held responsible. Terrible tragedy!

Realy well done and well explained, I admire your confidence and conviction to your opinion. No one else spoke about this issue as honestly as you did. You earned my utmost respect!

What a Gracious and Non - judgemental comments. We need coworkers like you , Dr Cellini.

"We're human and we make mistakes"... Tiny mistake, tiny punishment; big deadly mistake, big punishment where you don't lose your life and get some jail time... Seems fair. You have great power in these syringes and with it comes great responsibility. Quit your job if you can't do it properly. In fact, if any action you perform puts others in danger, yeah, don't do that either. Malpractice insurance shouldn't be used to protect a murderer.

That's flagrant malpractice. It doesn't take a medical professional to see it was careless.

This poor nurse was in trouble from " Go". She was in an unfamiliar area, outside of her area of comfort and using a flawed medication delivery system. She told the truth and in this debacle so both her AND the hospital should be held accountable. She thought that truth would help to right her wrong. As usual the Nurse is the fall guy. As a nurse for over 37 years, I think this will only result in fear and an exodus from the profession. The Lewis Blackman law was the result of phycians making questionable judgments that harmed a patient. They were NOT criminally charged. This case should have resulted in a Process Change NOT prosecution. This nurse made a serious error. It was not malicious instead this reveals that due to staffing issues nurses are pulled to work in some questionable situations. Something horrific happened but to use this woman as scapegoat after she has lost her license will do nothing for our Healthcare System. This might be a win for overreaching prosecutors but it's a sad day for the Nurse. We are disposable and the lowest on the food chain. Physician's errors are handled quite differently. I weep for the " bedside nurse" because when they pour themselves out to care and comfort their patients ,who cares for them when they get into trouble?

Genuinely terrified by how many medical professionals see no issue with medical malpractice 😭 saying “this could be any medical professional” … maybe but it could also be any patient, such as you or a family member, life threatening mistakes are not just a small expected error!! She OVER RODE the system!!

I had a nurse forget to start a med for me recently. Nothing at all serious, it just delayed my leaving a bit and created a bit of a scheduling issue for the other patients. The thing was, I was asleep. She could easily have woken me and sent me on my way, on time, with no one the wiser. I’d have had a flare in symptoms, but no way to know why. She didn’t. She woke me, calmly explained why I was delayed and apologized. Then, she found her supervisor and explained why things were slow. That kind of integrity is admirable, and we shouldn’t do anything to discourage it. Avoiding mistakes happens with adequate staffing, higher wages, vacations and caps on overtime. These are all more expensive than scapegoating.

1. Criminal negligent homicide does not require intent. If intent were involved it would be either 1st or second degree murder. 2. She didn't accidentally grab the wrong medication. She knowingly used a medication which was not prescribed. That is where the Criminal negligence comes from. 3. Just because the hospitals response was to cover everything up and settle on the side does not have anything to do with her actions or have any weight in whether or not she is guilty. 4. The fact that she is no longer allowed to practice has nothing to do with the case either. Now with that said there needs to be more action taken in this case. If they got caught trying to cover this up, what else have they covered up and so far gotten away with?

Saying she shouldn't be prosecuted for killing someone because they took her nursing license is like saying a distracted driving shouldn't be prosecuted for killing someone because they took their driver's license. If you take a life you should be held accountable.

It is important that medical personnel put their egos in their back pockets and hold each other accountable.

I am a nurse and been practicing in LTC since 1995..I am currently looking for assisted living or home health ...too much work. No time to do it and demands unrealistic..my heart goes out to the family of the deceased as well as the former nurse..

This isn't a mistake. She overrode the system pick ed the actual wrong medication. Ignored the warning labels on the medication. Mixed the medication because it came in a powder. Injected the medication. Those right there are deliberate actions. It's wonderful that she brought it to everyone's attention, afterwards. But again she knew she was giving the wrong medication how is this defined as a mistake. She overrode the system and willfully picked a different medication. If she had a problem with not finding versed she needed to do it right then and take it up with the pharmacy or the doctor. A paralytic is not a sedative! Again if she couldn't find versed and she actually had authority to administer another drug it should have been another sedative. And if she's not familiar with paralytics as a nurse working in units, patients need to be very afraid. Paralytics are used for specific instances. They are not used to calm you down. So for the uninformed with regard to paralytics, this poor woman that lost her life was fully aware of everything that was happening. A paralytic only paralyzes your body, your mind is still alert and so are your eyes and ears. I am 30 years emergency room and 10 years virology lab. And I've done every rotation under the sun.

Not surprised when something like this happens in a hospital, Doctors and managers always try to cover it up there is always favoritism for certain employees. I have seen a lot of things when I was a intern in hospitals. Malpractice and negligence is something that happens a lot, don't leave your loved ones alone if they are admitted into a hospital and ALWAYS ask questions even if the nurses or doctors get mad or bothered, it is within your right to ask as mamy questions as you wish.

This is sad and frightening. I have been a nurse for 17 years. I left bedside nursing and returned ten years later. So much has changed but the main thing is to slow down, check and verify what you are doing. I have been before the TxBNE twice….When these types of things happen you will definitely be standing alone and have to speak on your own behalf about your actions.

Thanks for this video. It could have been any nurses. I’m a nurse for 32 years in Chicago. We are overwhelmed daily due to staff shortage . We are ONLY humans. I felt bad for Miss Vaught😢

As an anesthetist for 12 years I don’t push a drug unless I know more about it than anyone else in the room. This “nurse” did everything wrong and murdered her patient in the most horrible way possible. She disregarded all safety protocols and didn’t monitor her patient after giving a drug. She should go to prison, we are grown ups doing a grown up job… act like one and accept the consequences when you screw up.