Andrea Lema - Root Cause Analysis by Andrea Lema https://padlet.com/brucea81/8oumy5zrh3sjouvd RaDonda Vaught Homicide Case en-us 2023-09-17 23:48:39 UTC 2023-09-19 16:54:03 UTC hello@padlet.com http://medicalandhealthcare.com/wp-content/uploads/2013/08/nurse3.jpg RCA Description brucea81 https://padlet.com/brucea81/8oumy5zrh3sjouvd/wish/2707751139 the structured method used to analyze serious adverse events.]]> 2023-09-17 23:48:39 UTC https://padlet.com/brucea81/8oumy5zrh3sjouvd/wish/2707751139 brucea81 https://padlet.com/brucea81/8oumy5zrh3sjouvd/wish/2707751140 The goal is to identify any underlying problems in processes that increase the likelihood of an error with a non punitive approach. ]]> 2023-09-17 23:48:39 UTC https://padlet.com/brucea81/8oumy5zrh3sjouvd/wish/2707751140 brucea81 https://padlet.com/brucea81/8oumy5zrh3sjouvd/wish/2707751141 The purpose of RCA in my nursing area as Hospice RNCM is to identify the failure of not managing critical symptoms of severe pain and respiratory distress.

- Identify ways and implement a system of order sets to put into place for each patient.

- The objective is to provide maximum comfort during the dying process. ]]> 2023-09-17 23:48:39 UTC https://padlet.com/brucea81/8oumy5zrh3sjouvd/wish/2707751141 Was this preventable? Yes, no, maybe? brucea81 https://padlet.com/brucea81/8oumy5zrh3sjouvd/wish/2707826211 Continued Factors and causes- What happened, how and why?   

Ms. Vaught typed in the letters, VRE instead of the generic name of Midazolam. The other name for Versed. The cabinet door popped open and offered Vecuronium.  It is documented that Ms. Vaught overlooked or by passed at least 5 actual warnings displayed. 

- She also did not realize she was pulling a powder vial, instead of a liquid vial.  She was often told to override to avoid delays in medication administration. It was later heard in testimony from other nurses that the system was constantly having technical difficulties often that year.

- The medication Vecuronium is a paralytic medication used when a patient is intubated in an emergency. It causes muscle paralysis which led to the patient not being able to breathe. It also caused her not to be able to call out for help. Therefore, she quickly became hypoxic which led to her death.  A critical component is that Ms. Vaught did not pay attention to the PARALYSIS warning on the vial top!! Ms. Vaught administered 1 mg of this.  

- Ms. Vaught also was not able to scan the patient's band, for the scanner did not work. There were no working scanners in radiology available. 

- Ms. Vaught also did not stay with this patient to verify she was stable. She should have stayed to monitor any changes in her condition. Let's say she did give her the right medication; she could have been very anxious still going into the scanner. 

- Ms. Vaught returned to the ER and within 30 minutes patient Charlene Murphey was brain dead from the mistaken drug due to suffocation and cardiac arrest. 




]]> 2023-09-18 01:02:47 UTC https://padlet.com/brucea81/8oumy5zrh3sjouvd/wish/2707826211 The RaDonda Vaught Case at Vanderbilt University Medical Center in Nashville, Tennessee brucea81 https://padlet.com/brucea81/8oumy5zrh3sjouvd/wish/2707855116 CASUAL FACTORS TO CONSIDER 

On December 27, 2017, RaDonda Vaught was working as a Float nurse in the ER and often worked in ICU at Vanderbilt University Medical Center.  Ms. Vaught was only 36 years old and had been hired to work at VUMC in October 2015.

-It was 2 days after Christmas, and the units were working understaffed.  Ms. Vaught was orienting a new nurse this shift.  Training a new employee brings on added stress. 

- Compassion fatigue, hunger, alarms, being rushed.

- Radiology called asking her to administer Versed to a patient undergoing a scan and was claustropic.  This patient was 75-year-old Charlene Murphey from Gallatin, TN. Mrs. Murphey was being treated for a brain bleed and had improved. 
- Some may ask, could Ms. Vaught have the trainee pull the medication without leaving her side. This could have been a good learning experience for the trainee. Not to mention likely not pulling the wrong medication.

- Another factor is nurses running on "auto pilot."  Overworking too many hours. No breaks.




]]> 2023-09-18 01:24:45 UTC https://padlet.com/brucea81/8oumy5zrh3sjouvd/wish/2707855116 The aftermath and backlash.... brucea81 https://padlet.com/brucea81/8oumy5zrh3sjouvd/wish/2707902978 Ms. Vaught soon discovered her tragic mistake after the death of Charlene Murphey. 

The empty vial contained the name, Vecuronium NOT Versed! 
As Ms. Vaught tearfully says, "My heart dropped to my feet."  in her Nightline interview.  

Ms. Vaught admitted her mistake immediately. VVUMC fired her. The family of Charlene Murphey received an out of court settlement and was banned from ever discussing the case. 
 

]]> 2023-09-18 02:03:18 UTC https://padlet.com/brucea81/8oumy5zrh3sjouvd/wish/2707902978 Was VUMC going to handle any repercussions? brucea81 https://padlet.com/brucea81/8oumy5zrh3sjouvd/wish/2707922663 Many ask what about VUMC and their responsibilities in this case?

Great question! 

VUMC fired Ms. Vaught and settled with the patient's family in early 2018. Settlement amount not publicly known.

Interesting facts related to the VUMC response-

Had Medical examiner sign off on death certificate as death was from Natural Causes not a med error. 

Did not initially report error to local, state or federal authorities such as the Tennessee Department of Health.

Quickly settled out of court with family.

Failure to keep medication cabinets or Pyxis's maintained and free from technical difficulties on a regular basis. 

The state only pursued penalties and then criminal charges against Ms. Vaught only. ]]> 2023-09-18 02:16:56 UTC https://padlet.com/brucea81/8oumy5zrh3sjouvd/wish/2707922663 Ms. Vaught's nightmare worsens. State of Tennessee vs. RaDonda Vaught brucea81 https://padlet.com/brucea81/8oumy5zrh3sjouvd/wish/2707939931 Ms. Vaught was charged with Reckless Homicide and Abuse of an Impaired person by the state of Tennessee.  

Peter Strianse, Attorney at Law representing Ms. Vaught

Glenn Funk, District Attorney who prosecuted the case in Davidson County, TN.
 ]]> 2023-09-18 02:28:40 UTC https://padlet.com/brucea81/8oumy5zrh3sjouvd/wish/2707939931 Nurses rally in Support of Ms. Vaught and what did we learn from this case?? brucea81 https://padlet.com/brucea81/8oumy5zrh3sjouvd/wish/2707961788 A shared accountability from both the medical staff and their employers. Hospitals, facilities and offices have the responsibility to ensure that all technical issues are handled swiftly and efficiently.  The staff has a duty to be forth right and honest with their choices.   

Extensive annual education on medications, time management, asking for help when needed, taking needed breaks needs to be mandatory. I have worked in hospitals where we could get assist from our supervisors.

Nurses from all over the country were in shock and fear over the first criminal case of a nursing error.  Could we also be charged and face prison for a mistake?!  

As nurses, we have a right to rest, breaks, not being forced to work overtime.  We need to have the right to say no to anything we do not feel comfortable doing.  

I believe after doing the research on this case, that yes there were mistakes that could have been prevented. Yes Ms. Vaught should not practice anymore. However, I do not believe prison was appropriate.  She has to live with what she caused every day and that is punishment enough. 

]]> 2023-09-18 02:44:52 UTC https://padlet.com/brucea81/8oumy5zrh3sjouvd/wish/2707961788 My personal Philosophy brucea81 https://padlet.com/brucea81/8oumy5zrh3sjouvd/wish/2707993641 As a nurse, I really value the trust and the ability to make decisions. However, I seek guidance and help if I need it. We worked too hard to become a nurse. I do not take it lightly and I treat all my patients as I would like to be treated. I always have the responsibility to myself and to them to do my best. ]]> 2023-09-18 03:08:05 UTC https://padlet.com/brucea81/8oumy5zrh3sjouvd/wish/2707993641 REFERENCES brucea81 https://padlet.com/brucea81/8oumy5zrh3sjouvd/wish/2708013500
Gluck, F., & Timms, M. (2022, May 13). Radonda Vaught sentenced to three years probation on a diverted sentence, could see record wiped. The Tennessean. Retrieved March 3, 2023, from https://www.tennessean.com/story/news/crime/2022/05/13/radonda-vaught-sentenced-vanderbilt-nurse/9717529002/


https://www.tennessean.com/story/news/crime/2022/05/13/radonda-vaught-sentenced-vanderbilt-nurse/9717529002/

Kelman, B. (2022), In Nurse's trial, witness says Hospital bears heavy responsibility for patient death.

National Institutes of Health.
https:// www.ncbi.nlm.nih.gov


Ramsay, M. (2022, June 22). Lessons learned from the Radonda Vaught case. Patient Safety & Quality Healthcare. Retrieved March 3, 2023, from https://www.psqh.com/analysis/lessons-learned-from-the-radonda-vaught-case/

https://www.psqh.com/analysis/lessons-learned-from-the-radonda-vaught-case/
Links to an external site.





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