ANY “nurse” who claims they haven’t had an “Oh my God” moment is either a liar or NOT a nurse. The panic fades only after one realizes that they didn’t mess up. Shame on those who are being judgmental, especially if they’re licensed healthcare professionals. But for the grace of God...

I read the CMS report in its entirety, and it's a laundry list of systems errors. Yes, the nurse has a professional responsibility re: med admin practices, which seems like it was investigated by her state BoN. But the hospital was just *drowning* in inadequate systems and *utterly insufficient* institutional response. She is absolutely being hung out to dry as a scape goat.

Any death is a tragic event, but this type of legal behavior will just further dissuade more well-intentioned people from entering or being a part of healthcare when we’re already in a healthcare provider deficit.

they need to pass laws about patient ratio/safety. Nurses are overworked and management keeps piling more responsibilities on nurses to keep costs down.

As a retired Deputy sheriff, this sounds like a civil matter, more than a criminal matter. The question is who is bringing up the charges. I would bet that the hospital is behind pushing for a criminal charges. That would likely save them from civil penalty. I wish her luck. Most of us on the front lines of public health and safety get throne under the bus if it is to save the administration. Z Dog you sir have a great day.

The fact that Vanderbilt lied to the Medical Examiners office about the circumstances surrounding her death tells me everything I need to know about the culture of transparency and openness for process improvement.

This case makes me scared to stay in nursing. It could have happened to anyone and companies will just throw you under the bus faster than you can blink

Thank you for your support. This is the only place we get it. Nurse out.

Finally a doctor who cares enough to take a stand for a nurse!!!!

This terrifies me. I’ve had med errors before. So many meds to dispense, in such a short amount of time. Too many people with serious needs and not enough time to be everywhere at once. Passing meds while dealing with the guy with seizures and the guy bleeding out and the lady with dementia and the bells ringing and supervisors breathing down your neck. We’re expected to be superhuman and perfect all at the same time. It’s horrible what happened and I’m sure this nurse feels the guilt every day and will for the rest of her life. Jailing her is a terrible waste.

CEOs make calculated cold-blooded decisions to increase patient to nurse ratios, patient to doctor ratios, mandatory utilization of higher & higher numbers of nurse practitioners supervised by fewer numbers of doctors. The administrations at many facilities singular goal is to increase the speed of the patient conveyor belts from the second they hit the ER. Caring for patients is viewed as nothing more than the processing of widgets. And you are surprised the administration threw this reputable nurse under the bus???!!! Administrations seek their financial goals while putting all the responsibility on the “providers”. Welcome to healthcare 2019. This scenario could have happened anywhere in the U.S.. I’m a hospitalist & I am sickened.

The nurse made a grossly negligent mistake but that is just what it is, a mistake. I can't wrap my brain around how she is being criminally charged for this without any evidence that she maliciously intended to harm that lady. She already has to live with the knowledge that she killed a patient. There's no justification for putting her in jail without holding everyone involved with that case accountable. I always tell my EMT and paramedic students "you will make mistakes, just strive to be as good as you can be to avoid the BIG mistakes"....

Honestly, this is exactly why I’m trying to get out of bedside nursing ASAP after being a nurse for only a year and a half. There’s too much liability and we’re not compensated anywhere fairly for that. I could work an office job, make more money, and wouldn’t have to worry about losing my license and being thrown in jail. This woman, while highly highly highly negligent, not only lost her livelihood but also faces life-altering criminal charges. How is it that hospital administration makes more than we do with none of the liability, yet they were equally as liable?

As someone who works in the radiology department here at Vanderbilt I can assure you that we are more than replaceable. I does not help that we have a disastrous turn over rate and the people with years of dedicated experience sometimes don'thave a voice on how we can improve systems and protocol. At the end of the day everything is first looked at through the eye of will this cost the department money. In CT and fluoroscopy we always do a time out for any type of contrast or drug administered. The MRI techs should have also done this with the nurse. This is heart breaking because an individual who dedicated her life to serve others is now paying the price not just of her mistake but the sin pride and prestige of the VUMC.

A paralytic should not be in any Pyxis.

I’m an ICU nurse... the biggest mistake here isn’t actually administering vecuronium in error (though that’s clearly an inexcusable error). Rather, it’s the fact that the patient was left unmonitored during the scan. And that isn’t entirely the nurse’s fault either. This was probably an MRI scan, and you patients can’t have anything metal on them including most normal monitoring wires). No A-line transducers or normal O2 sat probes (which would have almost immediately notified the nurse that the patient was paralyzed and couldn’t breathe). Unfortunately, even though there IS a wireless MRI compatible O2 sat monitoring system that has been commercially developed, it wasn’t available in this instance. I think it’s dangerous to place ANY patient into a metal tube for up to 45 minutes on minimal monitoring when there are alternatives available

This is so scary. Kinda makes me want to hang up my RN hat. I cannot even imagine what this poor woman is going through...I would be in therapy also for the immense guilt. Administration at its finest, I totally agree with you and I shared this for sure!!

Wow May God be with her. This is a tragic event on both side. I hope a jury doesn’t find her guilty . This scare me as a nurse .

I completely agree, Z. This nurse is being thrown under the bus. As nurses we (literally) break our backs & work under high levels of stress w/ unsafe patient loads & our own hospitals won’t even have our backs. What happened at Vanderbilt wasn’t caused by ONE human; this was a multi-system failure we are talking about. My prayers are with this nurse as well as the sweet lady who lost her life as a result of this. No one becomes a nurse to do harm. ❤️ thanks for this video!

Coming at you with 100 % agreement in support if the nurse. Really appreciate your passion and support!

As a Rad Tech this is one of my fears. Not being able to clearly see or monitor my patients is not a good process.

Well said. I was caught in similar system failure that did not harm the patient, but lost my job of 12 years anyway. I can't imagine what this nurse must be going through. My heart goes out to her

As a nurse, I think this will only change when nurses and the nursing board stand behind a nurse accused of a crime the way doctors and the medical board stand behind a doctor accused of a crime. Doctors will typically rally around a doctor, but nurses will throw each other under the bus and "eat their young"

What prosecutor would take this case?? I’m 100% with you sir!!

Nurses adapt to poor staffing with short cuts which remain even when staffing is okay. Something has to give when you have too many things at the same time to do in reality, but all the management cares about is the charting and joint commission. It is dumb luck that horrible errors don't happen to more people.

Absolutely agree with ZDogg's message. This will make patients less safe, ultimately, not more.

Thank you so much for your support for nurses and other medical staff. I’ve been a nurse for almost 5 years and the worst part of the job for me is the verbal and emotional abuse from patients and their families, and occasionally doctors. I really appreciate you

It makes me sad but I wish I could love this video a hundred times! THIS is exactly the type of administrative response that makes me very adamant, when training new nurses, about the importance of your own malpractice insurance. Your hospital may say they have insurance on you but when the chips are down, they will throw you under the bus to cover their own behind! Unfortunately that insurance doesn't protect from criminal charges but it will be the best $100/yr you spend. So so many things wrong with this whole situation. We clearly don't do this job for the money. It's a passion and a calling. Nurse/patient ratios, length of stay, little protection on the front line, long hours without breaks, lack of respect between departments and doctor and nurses, poor systems all play into the likelihood of these mistakes becoming more frequent. Our system is already broken and will only be more irrevocably damaged if they successfully convict her. #IStandWithRadondaVaught

I love the research and light you shed on this. I can't agree more.

I agree with you 100%, she has paid and will continue to pay for the rest of her life, she dont deserve this, accident will always happen but this is not the answer at all

Thanks for being supportive...healthcare needs all catergories of caregivers working together...un fortunately there isn't any backup from management or administrators in hospitals for the caregivers..it's gone from bad to worse in the 30 yrs of being a RN..I'm so glad I'm retired now

As a nurse educator for 25 years, I love not only your videos of parodies, (which I use in class) but most importantly your advocating for nurses. I wish we had more multidisciplinary teams led by people like you.

2nd year medical student here and my heart goes out to this nurse. Completely agree with you Dr. Z.

And this right here is why I love ZDoggMD!!!

Thank you for standing up for her. I really appreciate this video.

There was a nurse in Wisconsin Juile Thao That felony charges were brought against for overriding safety procedures. This was in 2007. It was found she worked a 16 hour shift, slept at the hospital, and worked again. More needs to come out about the kind of work environment is at Vanderbilt. I will be following this closely! The whole situation is scary! A quote from Diana Richardson RN from the Wisconsin Hospital Association stated "health professionals enter Healthcare knowing that a mistake could cost them their license, livelihood, and financial stability. What is incomprehensible is entering a career where a single error could lead to imprisonment" :-(

Any one of us could have made this mistake... I’ve been a nurse for 10 years and know that everyday things happen that could be avoided. I can’t imagine the pain and suffering this nurse is already going through! I would absolutely be beside myself if I made this error. You’re absolutely right... we need a system where we can honestly come forward with mistakes and problems... not prosecuted for them. We want to keep patients as safe as possible and not cover up the problems.

Wow!! My heart breaks for this Nurse!! Sending my thoughts and prayers to her and the family effected during this time💔

Well said Z. This nurse will never recover from this. Anyone who has ever taken care of patients has come close to or done something similar.

As an ICU nurse 24 years what I can’t get out of my head is that she reconstituted a drug that she thought was Versed. Any seasoned nurse knows that Versed is not reconstituted. When she was required to reconstitute the drug that she had pulled that should have been a warning sign to stop. Also who pulls a drug and doesn’t look at the label? That being said a lot of the blame should be with the hospitals with their unsafe staffing ratios and their lack of institutional controls.

Every RN's nightmare...hospital will throw u under the bus in a NY minute! Thank you MD Z......Blessings and healing to this nurse.

The reason the nurse goes to jail, is because somebody has to pay, and the nurse is at the bottom off the food chain without power so she's the logical sacrifice to get back to business as usual. It's about money, and protecting the elites, not the patients or front line workers.

As an ex NICU nurse at REgions Hospital St Paul we were forced to take mandatory overtime. Even when expressing the inability to do a total of 16 hours with a 1-2lb infant and 5 + IVs going we were told it would be abandoning our duty and calls for firing! I put up with that for years! No parents ever knew. I’m sick for this nurse!

I'm living for your RAGE. How dare they throw her under the bus!!! She already paid for this egregious mistake.

That’s insane!! Heart goes out to the nurse and the family! I’ve made a mistake or 2. There shouldn’t be a way to override without a second pair of eyes. The national shortages alone should make it clear that we need the system and the processes to have our backs. We are humans!🤦🏾‍♀️

Her arrest will have an unintended consequence of worsening quality by hiding medical errors as opposed to trying to solve the multiple system errors which are typically the problem.

Thank you for standing up!

Thank you ZDoggMD for your support of the Nursing Community! We shall not break!

So who/whom are the parties pushing criminal charges? The patient's family doesn't want this, she has credible character witnesses and assuming her record is clean & clear I just don't see it. I'm pretty sure the District Attorney's office has more work than they need right now. So did they just "pick" this case out of the blue? I'm confused.

Do you wan a culture where nurses cover up every mistake they make and the system never gets fixed? Because that's how you get a culture where nurses cover up every mistake they make and the system never gets fixed

thank you for putting this video out

100% agree! Thank you for speaking my mind 👏👏

This is getting absolutely crazy! I believe if they arrested her, they should hold everyone accountable, including pharmacists, administration, and doctors.This is crazy!

In my view as a nurse I have the fullest respect for the pyxis machine and all the medications in there from the first day I was rrained and ongoing I bring my computer on wheels and verify the medication per the mar. I respect all nurses and the feeling this nurse is going through I pray over her and all medical staff. What we do is not easy and at times it is down right nerve racking but God gave us these to hands to nurture heal and hold. Be blessed my fellow nurses.

Zdogg your my hero I agree fully with you. I hope she does not get jail time.

Well said … Thank you for speaking on this!

This RN is with you 100%! This never should have happened, but I totally understand how it did. The fact that a patient receiving even the slightest sedation for an MRI was not being monitored is mind boggling and terrifying. My heart goes out to that nurse.

Maybe we should start refusing to provide care if they make these impossible conditions. Then the whole system will break because it’s like that everywhere.

Zdogg, you make so much sense about healthcare priorities and the atrocities of healthcare today. I listened to your “burnout” video and it woke me up to how I have been feeling lately. I left healthcare for the very reasons you mentioned. Thank you for being a voice of reason.

I agree with you, Z. Thanks for speaking out!

Well said, Doctor. Unfortunately, there are no leaders. An epic tragedy on all sides

Just juxtapose cops and nurses for a sec. If a cop shoots someone to death by mistake thinking the suspect might be a threat, even in a non-threatening situation, the cop goes off scot-free most of the time. Now this nurse is being for charged for reckless homicide, for making a mistake. Both come from broken systems, one is allowed to go free, while the other is held accountable only to cover up the faults of the hospital. Absolutely disgusting and inhumane.

Agreed. Thanks for being a voice for our medical community!

Great lesson on leadership here. Thank you, Z Dogg.

I love that you can publicly lay out the “system errors”, identify professional errors, and their attempt to charge one administrator. Errors are made in “practice”, normally without intent, hence, a mistake. As health professionals, “we” understand the holes in the process that continue to plague our ability to provide safe care. Nurses already are stretched thin, there is a national shortage, and rumors hold that “we eat our own”. The system will quickly deteriorate if we instill yet another reason why nurses will fall away from the profession.

I agree 100%, ZDogg. It's ashame; another case of administration throwing staff under the bus. Despite my thoughts on the errors that occurred, I think it's absurd for her to have been arrested. No grounds for a criminal case, and just torturous to the poor nurse.

I am glad I am almost retired. Practicing medicine in America has become terrible. From administrators 'practicing medice', to corporate ownership stealing physicians compensation and now criminal charges for medical mistakes, the system is already ruined!

As a nurse myself this makes me absolutely terrified for a multitude of reasons. I absolutely agree with you about how this will make people cover up errors even more. I have so much stress every single day about going to work and making a mistake. The stress of being a nurse is REAL because of the fear instilled in us that things are our fault since we are the front line.

What a joke. Every prospective doctor and nurse in the country needs to pay attention to this. Go through intense schooling, get into crazy amounts of debt, work yourself to death for the good of others, get thrown in jail when you make a mistake that there should be a litany of safeguards to prevent. Good luck kids, Telehealth here I come.

I am sorry for all my fellow nurse practitioners, nurses, PAs, and MDs. A culture that criminalizes mistakes will hide those mistakes. We should learn from those and continue to find the root cause of these. A common goal of safety and shared knowledge is needed to prevent future mistakes. I am profoundly saddened by this news.

The fact that Vanderbilt hasn't changed their processes in over a year per CMS is a blatant sign that Vanderbilt Administrators should have been arrested instead!

Retail pharmacist here. A few years ago I grabbed a box of duoneb thinking it was budesonide and overrode it to save time. Turns out the patient had a non-severe allergic reaction to the albuterol and chose to visit the doctor, discovering the error. The patient returned and notified me of the error and I was mortified. It brought tears to my eyes. Fortunately, she was one of the kindest patients I’ve ever had and she insisted that I not hold it against myself. The morals here IMO are 1) we all make mistakes. Sometimes they are minor, sometimes serious. The factors that determine the seriousness are often beyond our control. 2) Always express remorse and apologize sincerely. Most reasonable people simply want an apology and do not want to destroy your life 3) learn from your mistakes. When similar scenarios present again, remember those past patients to help you avoid the same errors.

I don't think I even want to be a nurse anymore. Your waiter screws up, he gets a small tip. Your nurse screws up, she goes to jail. Why?

While no one can cast ANY stones at this nurse, I must, MUST say that when you look up a med and it doesn’t pop up, overriding the system was not the next logical step. When I’m trying to put in an order or grab a med, if I can’t find a mess under the commercial name, I take the one second and google that med. it usually gives you that name you looked up, the generic name ( which may be what you need to get the right med) and several other names it COULD be. The other errors were, yes, a result from a faulty system and overworked and rushed, but what I don’t understand is why she didn’t check for the generic name of versed.. even if she’s on older nurse...there’s a drug book in the med room, most likely... or go ask someone! “ hey I’m trying to pull this med and it isn’t coming up. Can you help me?” I believe this one not-checking-generic-names things was the downfall. I’m a fairly new nurse and I know I have years and years to learn, but even now, if I don’t know something or something doesn’t look or feel right, I look it up, or ask someone else until I have the appropriate treatment for the patient...I too am very overworked and underpaid and my plate is too full also....but Im still gonna make sure I’m doing the right thing. Please learn your generics WITH your name brand drugs!

Great job zdogg

Preach it Z!!! What really needs to happen for a true overhaul if the system is for Medicare and Medicaid to pull funding/ payment for any hospital that cannot adequately prove and show ongoing record of administration/ leadership, as you put it, enacting and monitoring good medical practices that are GOOD FOR THE PATIENT FIRST and not for profit margins. Any hospital that puts profits before it care should be shut down. Sadly, that would probably be most if not all in the US. What a complete tragedy on all fronts!!

We're gonna end up with no medications being able to be overriden in pyxis/ Omni machines. Arrest / criminal charges will not help. It will make hospitals and health systems be less open about errors. Reminds me of the pharmacist in Ohio that made the error in chemotherapy for a pediatric patient.

I agree with you completely based on the facts that are known/disclosed. Scapegoating this nurse by indicting her when she has already paid the high price of job termination and mental anguish is cruel. Furthermore, it points to a healthcare system that is unwilling to take an honest look at the multiple system and process failures at play in this tragedy. Whatever CAPA plan was submitted to CMS, it was likely superficial, especially considering how reluctant the institution is to release it to the public. If they truly addressed the root causes that led to this patient's death, why not be transparent and disclose it?

Work for a similar university medical system and our CNO has told us that safety reports cannot be discussed because they are a private matter. I have brought up that what I was taught in nursing school was that the purpose of these reports is to investigate areas that need improvement and how is our unit supposed to improve if changes are not made and mistakes are not discussed among the team to avoid them in the future.... crickets....

I missed a sepsis in an 11 month old child. It was one of those nights, waiting room out the door, patients lining EVERY hallway, some in chairs, most on a stretcher. I told the nurse to send in labs. The kid looked ok, but sleepy. I gave them explicit instructions to bring this kid back if ANYTHING looks different or worse. Lucky for me and the kid, the parents brought them back, with spots and a 104 temp. This happened while I was off duty, but the phone was ringing, and my supervisor told me what was going on. He thanked me for doing good patient returns if changed, and it was the worst week of my life. The patient got airlifted to San Francisco General and from there I lost track. I worked nights for 15 years, in the ER, seeing as many patients as was possible. Prompt Care for 6 hours and then Trauma for the other 6 hours. Nurses are the glue that holds this system together. If you start arresting them for working their asses off and making an error, everything will come crashing down. In defense of this nurse, a paralytic should not be in with the usual drugs. There has to be a way to separate them. I’m a PA so I did not have access to the drugs, I already had more then I could do anyway.

I agree. There was so many system errors this horrible accident is not criminal. My heart goes out to her.

Who, in their right mind, would ever want to be a nurse????

You are correct Dr. Z.... This is so sad to hear 😡

(20+Year RN here) agree with you Dr. z Thank You for being this situation to light.. so many mixed emotions, my heart hurts for everyone involved! Making mistakes as a nurse stays with us forever .. prayers and 100% support for you Rosanna (so sorry if I misspelled your name)

Without transparency more people will get hurt.

It is so disheartening that nurses do not really behind our own. We should be in the streets with signs and bullhorns behind this. The conditions and stress this RN was under led to this mistake happening. We as nurses need to fully educate the public on the realities of healthcare....the constant understaffing, increased patient load, increased charting requirements, pressure to "make the patient happy at all costs" even if its contrary and detrimental to the patients BEST interest. Not even counting the system failures incorporated in this. My heart goes out to this nurse. And I agree this is ridiculous, scapegoating and gaslighting personified.

I have been a nurse for almost 30 years. I have also read most of the replies to this video. First, reporting of medication error or medical errors in general are supposed to be used for quality improvement. Nurses etc. are not supposed to fear reporting an error. I find it funny, not really, that some people are damning this nurse for her error. Mind you, it was a doozy but she did not try to hide it. It was reported in good faith. She has probably suffered more since this happened by beating herself up by not following proper protocol, probably has suffered from guilt and depression since she realized what happened. But the bottom line is it happened, and we all have to learn from it. It is my understanding that she was floated to an area she was not entirely a costumed to. Her patient, whether going to CT or MRI should have been on a monitor to travel and should have been placed on a monitor in either radiology area she went to. It was not just her responsibility, there were others present.. You cannot tell me that a complete body scan would not have shown her not breathing with or without a monitor. The Radiology techs often talk to the patient during the scan, did no one ask this patient if she was ok during the scan, noting that she did not respond? A whole body scan for a subdural hematoma makes no sense. Why would they do that? The problem was in her brain... there are many questions I would ask. How much Versed was ordered? If she was unfamiliar with the area was she also unfamiliar with the critical care meds(versed is a critical care med), did she not know the generic name? For those of you that don’t, it is midazolam.... not even close to versed.... maybe the doctor should have known how it was written in the Pyxis ... maybe he should have ordered it that way.... if she was unfamiliar with Versed, maybe she didn’t know it didn’t get reconstituted.... she did not show malice.... if her defense needs an expert witness... they can contact any nurse educator that is not employed by Vanderbilt.... she should have had to go through training again to refresh her, but she should not be prosecuted

Thank you for being a voice to such a sad event. Often nurses get the short end of the stick, and a lot is required of them. I totally agree with your argument, and I hope that the nurse that this happened to is not criminally charged. It is so heartbreaking to hear how damaged and unmanaged the whole healthcare system is. But it’s great to hear that so many people want to see change, and that there are people like you who are the voice of the voiceless. Thank you for all that you do. When I get my nursing license, I pray that work with superiors whom are supportive and understanding!

My biggest complaint about incident reporting systems is they can be used against a person either vindictively by a fellow employee or by management even though the process is not supposed to involve punishment. The overall goal is correct but the process is flawed. They should make reporting systems anonymous, so it can’t be used punitively against the person(s) at fault if the overall goal is to correct flawed policies. Currently hospitals use the polices to deflect financial responsibility which they won’t get out of unless there is extreme gross negligence which will be reported by other methods anyways. It’s always about the money.

Preach z Preach! This case is such a threat to our system, and as you said will only darken the waters by creating fear and a punitive driver to our choices.

I agree with you, Z! I support this nurse, she has suffered enough. I have been an OB nurse for 25 years now, and I understand the stress of tragic incidents. Each baby that is born with my name on its chart, I'm liable for 21 years!!!!! So sad for this nurse and her family.

Well said! This CANNOT become a new standard reaction to mistakes. Shared to Twitter and Facebook. We’ve got to get the word out.

I frequently end up in situations where it is unsafe nursing for the nurse as well as the patients. One incident I was working agency and went to a rehab facility expecting to take care of 15 patients. I ended up with 30 due to the facility not wanting to have an additional nurse there. Can we say an accident waiting for a place to happen due to the management? They don’t care for anything but the money they can make. Incidents like this nurse went through are far to common and we as nurses are always blamed.

Disagree. It is the sheer LAUNDRY LIST of errors that she made that makes HER accountable. If she had used her nursing training AT ANY POINT in this sequence this woman would still be alive. 1: overrode the Pyxis 2: pulled wrong med from Pyxis 3: reconstituted a drug and ignored THE BRIGHT RED LABEL THAT SAYS PARALYTIC!!! 4: versed does NOT have to reconstituted!! 5: administered said wrong drug and walked out without assessment!! If she had stayed 2 mins that would have been enough to know the patient was crashing! This scenario tells me she had ZERO clue about the drug she was supposed to be giving and didn’t bother to take the time to look it up or, HELL, call the PHARMACY!! Who the hell gives an IV push sedative and just walks out and leaves the patient??? Here we don’t give Versed outside of conscious sedation which means continuous monitoring. So...Using your argument... we should not punish accidental deaths because there was no intent to harm. Should we not punish drunk drivers when they kill someone?? What about people that accidentally hit and kill pedestrians?? I don't hear any calls not to punish these people because everyone knows that the deaths are mostly preventable when vehicles are operated as trained and in a responsible manner. The same applies to this scenario...this was preventable and because she acted in a way that was contrary to training and irresponsible someone died. This was not just ONE med error...it was a series of tragic F-ups!!! Quite frankly - you are all giving her a pass because you are superimposing yourselves into this situation... you don't want her charged because, in your own minds, you are covering your own asses. Quite frankly it's disgusting and you all should be ashamed. You all want to talk about precedent?? What kind of precedent does this set if she is just allowed to go?? It tells our patients that their lives are not as important as our individual freedom and that when it comes to errors, we would rather stick together than stick up for them. It tells future nurses that it's no big deal to make dangerous mistakes because they will just get bailed out by their fellow nurses because we got each other's back. Not this nurse.

Thanks Doc I love your vids!!!

Good show! This was a tragic accident. If every healthcare professional that ever misdiagnosed a patient for even the most minor issue, there would be no one in healthcare. This case is sad. We're behind you!

I tend to agree with ZDOGG on this one. The five rights of medication should just be a coaching and counseling session for her and the fact that she went on unmonitored in radiation speaks more about the protocols that are put in place that need to be re-valuated by administrators

Throwing this woman under the bus will not fix the system or the problem. Fix the problem. Make it impossible to put a sedated patient in an unmonitored bed. Make it impossible to pull a paralytic by accident. Throwing her under the bus only allows more accidents and problems . Prosecution of her fixes nothing and allows a broken system to continue “ as is”. Make this accident impossible to happen again and you will save lives. This woman is being prosecuted because she is human . Humans are not supposed to be perfect. They can’t be. The administration is paid big bucks to create a system the leads to safer care. Clearly they have not done so.

Leadership will never held accountable and that's the biggest problem!

The more I read the more upset I get... The nurse was hired for an ICU in Oct 2015, she received her license in February 2015! How in the hell did she have enough experience to be an ICU nurse? Fast forward about 2 years and something bad happens... I looked at the job posting for a neuro ICU nurse and found that they only require 6 months experience, so I guess she had that... it also mentions that the unit has "charge nurse help all" so does that mean she was a charge nurse? After this happened, Vandy did not report this sentinel event (required by law), hid it from the ME, settled out of court with the family (with a NDA) and fired the nurse. The hospital only took action (other than paying off the family and firing the nurse) after there was an anonymous complaint filed with CMS and the investigation from CMS found that they were in violation and if they did not fix it they would lose CMS $. That got their attention, so they revised some policies, changed what meds can be removed with an override, and outlined a plan to train nursing. And it only took them just under a year to fix their flawed system that set up the conditions that allowed the nurse to make her error. So the hospital hid evidence, failed to report, and only changed the system when they were called out, by CMS, with the threat of lost income... but the nurse is the one being charged with a crime. What about the administrators? No charges for falsifying records? Failure of their duty to report? Attempting to cover up the incident? No? Why not? Because a nurse who makes about 50-70k/year is a much easier target to go after than a hospital admin who probably makes > 150K/year and gets bonuses = to a years pay for a nurse. Now I see that she has lost her license, and is being fined $3000 and is responsible for "costs" of up to $60,000... plus she has to pay her counsel, and still has the trial to go. And people wonder why there is a nursing shortage... @ZDoggMD how about an update video? Job posting: vanderbilt.taleo.net/careersection/.vu_cs/jobdetail.ftl?job=2000144&tz=GMT-05%3A00&tzname=America%2FChicago Board of Nursing order: apps.health.tn.gov/Licensure/DisplayPdf.aspx?profCode=1703&LicenseNum=205702&ActionDate=7/23/2021