This nurse was crucified ! She was set up for failure ! If a Doctor makes a mistake , he ends up practising in another State . The lesson here for nurses is to keep your mouth shut , and get a lawyer , STAT !

There was no order to ignore a nationwide standard of care. Period. The doctor told the family he'd look into it. No verbal or written or er was transcribed into the informatics.

Wow!

The "thought process" that someone in the organization ALWAYS puts first is cost, not patient safety. The reason they don't have a scanner in radiology is because they are expensive. I have pulled policies and shown them to my supervisor who has said "this department doesn't follow that policy" because the policy is inconvenient. If we did the 5 rights/3 checks every single time, it would slow us down and they'd have to keep us well staffed. We report near misses and hear crickets. I am so happy I don't have to work inpatient.

I just came across this video... you need to create one of these for Covid vaccine vials. As a vaccinator, we have multiple vials we are drawing from (depends on age group and whether immunocompromised). Pfizer manufactures both monovalent and bivalent vaccines that have the same color vial and vial cap. Moderna has a "magenta" vial and Pfizer has a "maroon" vial (very similar names and colors). Several of the vials have blue caps. Children who turn 5 during their primary series jump to a different vial. Many RNs are refusing to vaccinate with Covid vaccines because it's become so complicated and they are afraid of making a mistake.

Accidents are unavoidable, this was not an accident. This was extreme gross negligence and professional incompetence on the highest level. It’s like saying I accidentally hit someone with my car, but I was drunk, high, had bad brakes, no inspection, no license, lights not working, broken windshield…but sure it was an…”accident” sorry but she’s guilty

Love this! Great place to get the facts and to learn how this could have been prevented.

Just culture vs blame culture.

Warning. This video is about selling product using the R. V. case. I have 25 years at hospital bed side care, 10 of those years in Neuro ICU and stepdown unit. Who is the girl wearing a lab coat and stethoscope? Not all facts stated are correct, some of the guys statements are off. I have also read the federal/CMS report. Also clinical educator for 4yrs. Hey TapRoot if you need help with editing content let me know.

Simple! For younger generations. DONT TAKE NURSING COURSE just maybe of high pay salary or your jealous because they're wearing white uniform, or just because of your family tell you to become a Nurse.. BELIEVE ME BOOKS AND ACTUAL WORK IN HOSPITAL IS DIFFERENT. You can't SAY STOP for admitting patient to admission personnel because your tired enough to take care of 15 patients. You can't complaint because your a nurse and you need to take care of them because no one will do.

ugh so much tip toeing around the elephant called negligence

While I appreciate that you believe you are well intentioned - there is far more to this story and performing a complete analysis than relying on only those facts made public. Please remember that there is a lot more that is not released or readily available that will impact the analysis. During litigation the attorneys only present the facts to substantiate their respective positions and not all of the facts. You cannot say with 100% certainty that each one of those mistakes are due to a lack of processes. There are all kinds of other contributing factors. Until legislative changes are made, and well-intentioned software vendors are participating in meaningful changes accidents like this will continue to happen.

The difference between the other nurses that had been overriding medications and Radonda is they looked at the medication they pulled. I’m sorry but I figured what was wrong without a graph. Do you honestly need a policy in place to remember to look at a medication when you pull a medication from the pyxis. Stop overcomplicating it. Had Radonda done that alone, the patient would still likely be here. The system didn’t fail Radonda…Radonda failed the system by failing to meet the bare minimum standards of care for nursing. Don’t believe me go blindly pull a medication from the pyxis and give it without looking at the vial. Not going to do it, wonder why? Stop passing blame to further your own narrative. Want to avoid this situation again? Look at your medications no matter if you are a nurse, paramedic, respiratory therapist, and even physicians. Still not convinced that Vanderbilt is to blame

For more about TapRooT® RCA Training, see: www.taproot.com/solutions/rootcausetraining/

One nurse and ONLY one nurse killed Charlene Murphey. Radonda Vaught! Her egregious "errors", TEN in all, were so far below the standard of care and ultimately causing the death of her victim, she deserves the criminal charges and conviction of her PEERS that she got. I hope the judge throws the book at her when she is sentenced.

I agree that many should take ownership in this mess, but she failed the fundamentals here. We’re talking stuff you learn on day one in school.. the stuff to cover your ass so that the “system” doesn’t crucify you. I wholeheartedly disagree that the system failed her entirely. In the end it was her responsibility to not cause harm (especially since it wasn’t her patient), yet she made an unfortunately tragic and incompetent error.

These are well meaning people but this type of RCA is almost useless and does not get anywhere a real "root cause." Lots of such tools exist and they are useless and misleading.

At 1:00-ummm, she did not do all that she could do. Systems are designed to help us prevent errors. They don’t replace good judgment. Either she didn’t know that Vec wasn’t Versed or she flat didn’t check the vial. There were overrides and warnings. No scanner in radiology? Still responsible for checking the vial. Furthermore, the fact that a scanner wasn’t available is even more reason for a double check.

Sorry this is well-meaning but based on more inaccuracies than I have time to address. Here is a compilation of as much trial footage and related commentary that I could find. Vanderbilt really screwed up *after the fact* but she showed stunning ignorance and hubris. Her admitting that doesn’t bring Charlene Murphy back. Let’s do better AND improve systems and safeguards. kzfaq.info/sun/PLzjkacgKi2KKH6RVU8L50oDbYcYhgZYm3

Honestly this case proves why I don't trust medical personnel in the US. I used to work as a ED and OR nurse in Switzerland and I must say already the fact that nurses here have no clue what kind of medications a pyxis contains is just horrendous! In Switzerland you have to know every single medication you are using on your patients. The override function isn't the problem! That is in emergency cases a very important and necessary function. The only problem here was the nurse on the first place, she pulls a medication out of the pyxis never looking at it, never double checked it and then the worst and most shocking in this is that she went and administered the drug without the obligatory safety check which you must have learned in every nursing school! Namely; the right patient, the right drug, the right dose, the right route and the right time! So she failed on so many levels. Even if she would have administered the right drug I find it weird that the patient wasn't required to be monitored. Versed is a sedative and can cause respiratory depression. Obviously this hospital does not practice the monitoring as a standard under the effect of Versed. I only learned it the way that the patient should be monitored after administering Versed.

Hindsight is 20/20. She thought the computer gave her the right medication. If she thought she had the wrong medication, I’m sure she would have asked. It is because medications have 2 different names, so she might have assumed it was the brand/generic names. Medications should not have 2 names anymore. Medication dispensing machine should not have auto populate. It is also easy to click on wrong medication when a list comes up.

And there it is - the sales pitch Disgraceful

Warning! This is sad. They are using this case as a sales tool. There are making statements such as "she was suppose to override". But earlier he stated policy was use override for emergency situation. This was not an emergency. There was so much about this video that was not helpful.

She hit the wrong med and she had properly looked up the drug she would have stopped then. If you don't recognize the drug you don't just give it! You can call pharmacy if you need to and they will explain the order. Pharmacy can call any MD and clarify the order also. I am sorry for everyone involved but especially the patient. The patient comes first.

The CMS report can be found here: hospitalwatchdog.org/wp-content/uploads/VANDERBILT-CMS-PDF.pdf I see some comments are focused on blame. Do you think telling the people who make mistakes to "pay better attention" or you'll be fired or put in jail is a corrective action that will prevent this type of mistake from happening again? Will punishment help improve the 200,000 to 400,000 cases of harm each year by well-meaning but overwhelmed caregivers working in weak systems? Or do you think the punishment of honest mistakes is an easy way out that prevents innovation in finding ways to support the caregivers who dedicate their lives to helping others? Everyone will come to work one day bored, distracted, or overwhelmed and will make a mistake. Expecting people to be perfect 100% of the time is never a good idea. Focus on the systems. And in the report, you'll read about the broken and failed systems that were supposed to help recognize and catch this mistake. It's so easy to blame and to pretend we could never make the same mistake, isn't it?