Lorie Brown, Nurse Attorney talks to Stephen Houlahan, a nurse currently running for U.S. Congress in California, discusses his nursing background, how he entered politics and became an activist. They also discuss how nurses can become activists and represent their communities as well as the issues and topics that he is passionate about and wants to change. Find more information on Stephen at ElectHoulahan.com. (317) 465-1065
How Easy Is It To Make A Med Error?
All of us have times of the day where we are operating on âautopilot.â We hop out of bed, go to the bathroom, brush our teeth, and groom ourselves for the day. Breakfast is usually the same every morning.
Even when we are driving, while listening to a song or news or just thinking about something, our brain can go on autopilot. Think of the times youâve driven past your exit because you were thinking about something else. It canât be just me!
Many times, we find ourselves on autopilot when it comes to tasks that we have been doing so long or which are repetitive. If we did not go on autopilot, we would be like our automatic nervous system and we would have to tell our heart when to beat and our lungs when to breath. However, when it comes to assessments, we tend to be keyed-in and are present and not on auto pilot because of the importance.
At Methodist Hospital in Indianapolis in 2006, NICU nurses caring for premature babies would retrieve heparin to administer to the babies when it was ordered. Tragically, the pharmacy technician had mistakenly stocked the medicine locker with dosages that were 1,000 times greater than what was required for the infants.
The treating nurses did not notice that the vial, labeled heparin instead of hep-lock, was a dark blue color rather than the baby blue of heparin. I can envision that they possibly may have been on autopilot and saw the first 3 letters, H-E-P, without realizing it was the adult dose of heparin rather than baby dose of heparin.
The mistake resulted in the deaths of 3 infants.
This is the same scenario with RaDonda Vaught at Vanderbilt Hospital of whom I have often written in the past. She mistakenly administered the strong paralytic vecuronium instead of the ordered Versed, resulting in the patientâs death. She was charged, tried, convicted, and sentenced for negligent homicide and abuse of a dependent adult. You can find more about this by reading previous articles archived in this blog.
As with the Methodist NICU nurses, Ms. Vaught may have been on autopilot, noticing the first few letters for both pharmaceutical (V-E) and tragically selected the incorrect one required for her patient.
Additionally, even speaking the names of some medicines that sound alike while on autopilot can also lead to a selection error.
When vials look so similar, have names that look and sound similar, it is easy to get them mixed up and possibly result in injury or, as in the Vaught matter, even death!
I do not need to emphasize that it is imperative for pharmaceutical companies to do what they can to differentiate the various medications by their labels, their packaging or even by their names [examples]. It goes without saying that the better the medicines are differentiated, the less likely a mishap will happen.
And, most important, since you are the last line of defense against a medical error, consciously shut off that autopilot and focus, focus, focus on what you are doing!
Radonda Vaught’s Sentencing
For more than three years, I have been providing you with updates on RaDonda Vaught, a Nashville nurse, who made a medical mistake and ended up not only losing her nursing license but having to face trial for criminal charges and was found guilty. Here is the latest in her troubled journey.
Last Friday, May 13, 2022, Ms. Vaught was sentenced for a fatal medication error in which she erroneously administered Vecuronium instead of Versed to a patient suffering from claustrophobia and about to undergo a CAT scan. She was found guilty by a jury of criminally negligent homicide and abuse of an impaired adult.
I felt the Judge was very deferential in her treatment.  In a sentencing hearing, one hears testimony from both sides as to aggravating and mitigating factors. Even the victimâs family testified that they did not want Ms. Vaught to serve time in prison.
It seemed that everything was on her side except for the prosecutors who felt her sentence should be exacerbated because of her conduct.
The Judge did not agree but was able to impose what is called diversion in which she gave Ms. Vaught three years of supervised probation, no prison time. If she successfully completes her probation, then her sentence will be dismissed or possibly even expunged from all records, just as if this conviction never happened at all.
This is a great result, but I think that everything Ms. Vaught endured to get to this point has been horrendous for her. She will have to always live with the fact that her Registered Nurse license was revoked and, more personally, that her care and treatment resulted in the death of a patient.
Elsewhere, 2 other criminal cases recently came to light. The first is Dr. William Husel of Columbus, Ohio who confessed to giving 10 times the legal dose of fentanyl to 14 critically ill patients, all who died as a result. Dr. Husel was acquitted on all counts.
In the second, Christann Gainey, LPN, was taking care of Herbert R. McMaster, Sr., who struck his head in a nursing home and subsequently died hours later due to a subdural hematoma. Ms. Gainey was required by hospital policy to perform neurochecks and vital signs on Mr. McMaster after the fall. She documented that she did the checks, but camera footage showed that she never entered the patientâs room.
Ms. Gainey pled guilty to this offense which was an intentional act because she did falsify the medical records.
I believe this case was different than Ms. Vaught who made an unintentional medication error. Albeit serious, it is still my position that Ms. Vaught should not have been charged criminally. Unfortunately, prosecutors have discretion, and, in my opinion, the prosecutor just wanted to make a name for himself.
It was sad that Ms. Vaught, who inadvertently made a medication error, was convicted of a crime while in the matters of Dr. Husel and Ms. Gainey, their actions were intentional and not errors.
A Win For Some Nurses
I do not believe any nurse wakes up in the morning saying to themselves, âI want to do drugs today!â
I consider substance use disorder (SUD) to be a biological condition where the brain has cravings for a particular substance, and nothing will alleviate it except getting that substance into their system.
Unfortunately, a nurse with SUD doesnât just wake up and say, âIâm not going to do this anymore.â It usually requires treatment and intervention.
Some nurses suffering from chronic pain subsequently develop a SUD for which the pain can be alleviated only through the narcotic or Suboxone which relieves the craving as well as reduces the pain symptoms.
It is unfortunate that in Indiana the peer assistance monitoring program, Indiana Professional Recovery Program (IPRP), is an abstinence-based program by regulation. It was a regulation promulgated by the Indiana State Board of Nursing through the rule making process.
The Board has been inflexible with those who are on Suboxone who need monitoring.
An aggrieved nurse brought a complaint to the Department of Justice stating that she had been taking Suboxone and in solid recovery for a year. However, for her to get off that medication to participate in the monitoring program would be detrimental to her health and well-being.
The Department of Justice agreed and opined that a person with substance use disorder in recovery has a disability and public programs that prevent access, such as the peer assistance monitoring program (IPRP), is a violation of the Americans with Disabilities Act.
I know that throughout the years, nurses on Suboxone had to agree to revocation or suspension of their license until they could get off the medication before being allowed to participate in the program.
It will be interesting to see if the Board will change their rules to allow people who take Suboxone to participate in the program or if they will require monitoring elsewhere. This is a big win for some nurses who require Suboxone to keep them from abusing narcotics.
This also has additional ramifications for nurses who take Adderall for ADHD or take a controlled substance for epilepsy to prevent seizures or narcolepsy.
I am glad that the Department of Justice does not see this as âa one size fits allâ approach and is meeting nurses with their disability where they are and requiring the Board to give them options.
The Amazon Treatment Of Health Care
Today, everyone expects the âAmazon treatmentâ meaning they want health care immediately!
The delivery of health care is no longer the general practitioner in your community who has been there for years caring for patients ranging in age from birth through their geriatric years.
There are same day clinics and pharmacies that see patients, there are walk-in clinics at hospitals and urgent care centers literally every mile or 2. You can even get a same day telehealth appointment with a provider.
Unfortunately, with this quicker, faster health care system things do not get accurately diagnosed and treatment is based on symptoms rather than diagnostic determination to find the correct cause of the ailment. More mistakes are possible.
Now, would you think this makes for good patient care?
I think this âMcDonaldâsâ way of medical care with patients not being properly diagnosed in a timely manner will lead to more medical malpractice claims against health care providers.
We have an âAmazonâ type practice of medicine because almost every health care provider is required to see a certain number of patients each hour. To get to a specialist or a proper worked up for a problem, it can take some time to see a specialist, even take a test and get the correct diagnosis and prescribed the requisite remedy treatment.
And, obviously, the more rushed the diagnosis and treatment, the greater the chance for error with the patient paying the price. This impacts nursing as well as patients want things now. We will see what the future holds and if this model of healthcare will continue.
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