Feb 082019
 

Tennessee law enforcement agents announced they had arrested and charged a nurse with reckless homicide and patient abuse for a fatal medication error she allegedly committed while working at Vanderbilt University Medical Center in December 2017.

The charges allege that the nurse intended to provide an ordered dose of midazolam (Versed) to an anxious patient with a subdural hematoma who was going into a radiology scanner. The nurse could not find the medicine where it was supposed to be, so she used an override function on a dispensing cabinet and distractedly took out vecuronium (the first "VE" entry) instead of Versed. The patient received the paralyzying drug, then experienced respiratory and cardiac arrest and died a day or two later.

It's unclear what exactly in the ensuing investigation led the law enforcement agents to pursue criminal charges, rather than to defer to the customary professional disciplinary processes. The complaint alleges that the nurse did not record the medication administered, and left without observing the patient after the drug was given.

Unlike midazolam, which is stored in liquid solution, vecuronium is a dry powder whose injection requires a multistep process called reconstitution: sterile water is drawn up from a separate vial, injected into the vecuronium vial, and agitated to produce the liquid solution that is then injected into the patient.

Homicide charges against health care professionals are usually reserved for cases of intentional harm or practicing without a license. This case falls under the third and most controversial category of "extreme medical negligence," also called criminal negligence. The classic example is an intoxicated surgeon who operates on a patient who then dies from a complication. 

There were numerous opportunities to avert disaster in this case; criminal charges against the nurse imply she deserves all or nearly all the blame. Perhaps the evidence will show she does. But -- just to ask two obvious questions from the available information -- why could the nurse not find the ordered Versed when and where it (apparently) should have been? Why was vecuronium accessible in a radiology scanning area? Changing either of these conditions would also have averted the death. Vanderbilt has been cooperating with the Centers for Medicare and Medicaid and with federal investigators, who criticized the university medical center's initial attribution of the patient's death to bleeding, which led the county medical examiner to record the death as due to natural causes, according to news reports.

Prosecution of health care workers for medical errors or professional negligence is exceptionally rare, and has been criticized and opposed in the past by the Institute for Safe Medication Practices and the American Nurses Association. A primary argument against prosecution is that because medication errors occur so frequently, usually without harm to the patient and often due to system factors, it is unjust to selectively prosecute (or discipline severely) those nurses whose patients happen to be harmed. This principle is referred to as Just Culture. Also, fear of prosecution undermines the culture of safety, including open disclosure of errors without fear of punishment, that health care leaders seek to promote.

On February 4 2019, the nurse was arrested and booked into the Davidson County Jail on a $50,000 bond.

SourcesTennessee Star, Tennessean, Ochsner Journal, NCCMERP, ISMP

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Former Vanderbilt nurse arrested, charged with homicide for medication error