00:10:11 - 05:10:11
Adrianne Fugett 00:08
Good morning. Good afternoon. Welcome to Medplace podcasting. I want to give a brief introduction to what we're going to be talking about today before I introduce our guest, but here at Medplace, we are reimagining healthcare, a new dialogue with risk and patients safety leaders, this is presented by Medplace. We're excited to bring new conversations with top risk and patient safety thought leaders from organizations across the country. Please subscribe to get the latest news and content. If you found value from this episode. Please share it with your colleagues to create a meaningful dialogue in your community. Also, if you're interested in participating as a guest here at Medplace, please send us an email at speakers@Medplace.com.
Today I'm joined by Dr. Stephanie Sanderson, who is a nurse leader at Sharp Memorial Hospital in Southern California. And today we're going to be talking about the RN case verdict in Tennessee and what that means for medical error reporting moving forward.
Now before I introduce you to Dr. Stephanie Sanderson. I want to give you all a brief recap of this case, in case you're not familiar, Nurse Vaught was found guilty of two charges criminally negligent homicide and abuse of an impaired adult after a medication error contributed to the death of 75-year-old Charlene Murphy. In December of 2017. The patient Miss Murphy needed to lie still for a scan. It was reported that she had claustrophobia and vault was searching for said a powerful sedative in the benzodiazepine family, Vaught attempted to retrieve the medication and weren't able to find it. She disengaged a safeguard, allowing access to more powerful drugs. Dr. Sanderson and I will actually talk about how this is a conversation all in and of itself. And it's actually not very uncommon. Across the nation. Vaught accidentally pulled back vecuronium which we'll refer to as vec. In this podcast, that's a paralyzing agent. She removed this medication instead by air from the cabinet and injected the patient with this medication. By the time this error was realized. The grandmother had suffered cardiac arrest and partial brain death. Murphy died on December 27 2017, as reported in the Tennessean.com, on July 23 2021.
I do want to point out that nurses were told in Vanderbilt emails to override safeguards so that they could get medications quickly and it was normal to do so. Quote, “overriding was something we did as part of our practice every day” Vaught said, you could not get a bag of fluids for a patient without using this override function. And I will say Dr. Sanderson, and you and I will get into this. But I do want to say for the audience, that may not be familiar with giving these drugs depending on the area that you work in, it is worth a stroll through Google to kind of see what these different bottles and labels and the tops of the bottles look like. So I will ask you to talk about that. But I do want to give a little bit more introduction into this before we get started.
So I think all of us can agree that nurse Vaught did make an egregious error but assigning criminal intent to her negligence really does not adequately address the extreme pressure that RNs find ourselves in, and how we can really completely check out. So we do want to talk about that with burnout, especially in light of what we've all experienced with COVID. I think that's needs to be part of the conversation as well.
So kind of moving along here. I am the RN VP of Clinical Operations here at Medplace and as I said, I'm here with Dr. Stephanie Sanderson to discuss what this tragic event means for patients, clinicians and all of healthcare. And as I stated, Dr. Sanderson has a doctorate in nurse practitioner with 38 years of nursing experience spending the last 28 years in the ICU setting. She has bedside charge and management background. Currently, she manages a 24 beds surgical ICU unit at Sharp Memorial Hospital in San Diego, California, where they care for open heart patients they provide ECMO, they manage trauma patients head injuries, and surgical oncology patients and full disclosure I will say that I had the pleasure of working with Dr. Sanderson when she was an RN in the medical ICU. So welcome Dr. Sanderson. We have a lot to talk about today.
Dr. Stephanie Sanderson 04:52
Yes, we do. And Adrianne, it's always a pleasure to spend any time with you whatsoever and I'm Looking forward to our conversation today about this very, very challenging case.
Adrianne Fugett 05:06
Yeah, yeah, me too. I hope, I hope that we have the time to get through all the questions. So I'm just going to kind of start going through it and see where we land. I would like to open with from a nursing point of view. What do you think happened? Dr. Sanderson, what do you think was possibly going through her mind and, and help our audience understand how errors happen, because we know they happen, I've made minor medication errors in in my practice, so kind of just help explain to the audience how that happens in general, and what you think happened with nurse vault in this case?
Dr. Stephanie Sanderson 05:47
Sure. So healthcare is something that I'm not in a hospital setting. I don't think that everybody understands sort of what is happening behind the doors of the hospital. And nurses are often put in a situation where they're overburdened with responsibility of patients at sometimes it not, it's not just one patient, sometimes it's three, or four, or six or seven. And the more responsibility a nurse has, the greater their burden is, and the more likely that they will make a mistake, because To err is human. We, as nurses, try nobody goes to work wanting to hurt anybody, or, in this case, to make a mistake that cost somebody their life, that that isn't what people set out to do in their day-to-day work. And having said that, hospitals also try to create systems to prevent those things from happening. But just like anything else, there's always a flaw in in those situations, and nurses often perceived safety as barrier to be able to getting the things that they need, in this situation, without really knowing everything that was going on in nurse VODs head that day.
It's safe to say that along with her work responsibilities, that she probably also had life, things going on. And in her own mind, and, and was in a situation where if she felt, if I if I recall the story, clearly, she felt rushed, she felt like she was being rushed, in this case, to do a procedure that is not really something in critical care. And MRI is not an emergency, typically. And so that struck me is very strange that she felt so pressured to get to get the procedure done. The other thing that I kind of struggle with is not really knowing why when she overrode multiple safety situations like they, I think that the medication cabinet redirected her several different times to are you sure this is what you want. And she just methodically went through this situation as fast as she could to obtain the medication that she thought that she was needed, and ultimately pulled out a medication that she had to reconstitute because Vecuronium, as far as I know, only ever comes powdered. It's and I believe that it's like that for a reason. Because it's like the last thing that you're doing as you decide that you're going to give that drug.
And again, to go back to override lists. Most hospitals have override lists that they've created. And they do that for a reason that one of the reasons is to prevent exactly what happened. But what it sounds like, based on what you described in the information that you disclose, what it sounds like is that overriding was a normal practice. And if you normalize the behavior in an environment and it's encouraged by the hospital itself, nurses will not know that it's that they should not be doing that it's being normalized. And they think that it's okay to do that. So I do believe that nurse Vaught was doing so Something that every nurse in the hospital probably did at some time. I also think that she may have been in over her head, I don't know how long she'd been a nurse or taking care of patients, it doesn't sound like the patient was, uh, was in the ICU. But this nurse didn't seem familiar with the medication that she pulled. And that that part of it is also very telling it, but at the end of the day, do I think that she should be criminally charged?
No. I do believe that, that her punishment for, taking away her nursing license, took away her livelihood. I do think that that was fair, but when other health care providers make even more profound mistakes, and don't get held accountable that way, there's that that makes me concerned. It also concerns me, because I want nurses to report errors. And if they're afraid that they're going to go to prison, they may not tell us if they've made a mistake.
Adrianne Fugett 11:17
Right? You bring that back concerns me as well. And you bring up several really good points. And a couple of things that I want to touch on is what people may not be familiar with in the MRI setting how we as nurses sometimes feel really rushed, when we're in the MRI with our patient, whether that's from they've got an overflow of patients. And so I can see that pressure being put on her. And the override issue. I know there have been instances in emergencies in my career in the ICU where I've had to override simply because it's asking me, do I really need the medication? And yes, I really need it. But I actually know what I'm grabbing. So can you talk a little bit about how it, it's not uncommon that a nurse would in some instances actually need to override and kind of when that, should happen and how that's supposed to work?
Dr. Stephanie Sanderson 12:22
Certainly. So override lists are something that are probably the bane of every hospital's existence, because you're trying really hard to keep people safe. And that's why that override is in place in the first place. What's important is that the medications on that lists need to be thoughtful and not set up in such a way that the way nurse Vaught describes that you had to override just to get a bag of fluid. It sounds almost like the list itself was limiting to the nursing staff and there wasn't a lot of thought put into what drugs do give routinely what drugs should be overwritten? Or on this list. What, how hard should we make it to get to those really scary drugs, it doesn't sound like maybe a lot of thought was put into that particular situation.
But as you mentioned, in an emergency, you may be asked to give something that isn't in the patient's profile. And if it's not in the profile, you'll be taken through a series of steps about overriding and it'll ask you several times are you sure this is what you want? And it's that machine is making an assumption that the nurse knows what they're doing, and that the nurse knows what the consequences of overriding are and what the consequences are of not having a pharmacist verify this. That's the whole point, right? You're giving that responsibility to the nurse. And if that person is stressed, overwhelmed, scared, got a lot going on. It lends itself to a problem. And in this case, I believe that the nurse didn't have the knowledge that they needed to make a good decision about, Do I really want Vecuronium or VEC? And, and sort of in that situation, I think that that hospitals don't really take that that piece into consideration. While I as a very, very experienced nurse have given vecuronium probably 1000s of times in my career. I would know exactly what I was asking for.
Adrianne Fugett 14:57
I think we froze a little bit what so what was that? Last point you were making,
Dr. Stephanie Sanderson 15:01
oh, I just mentioned that, that sometimes we, when we're not hospitals are making assumptions that nurses, all nurses know the same information when in fact, there's different levels of nurses on duty every single day of the week. And just because I know it doesn't mean the next one
Adrianne Fugett 15:24
will, I want that that's a really well, and you bring up a really a couple of really good points. So just for people to understand that override is a normal process in any hospital, but to be really careful that the drugs that are listed on your override medication list, need to be drugs that are have a lot of high risk attached to them. So in other words, if you're like doing it for reasons, you want to limit how much fluids or for whatever other reasons that that kind of created a pattern sounded like at this particular hospital, which again, I'm sure happens in other hospitals, it's not just this one hospital, it's just something for all of us as leaders and healthcare to be really familiar that these override drugs should be drugs that have a really high risk assigned to them. And that's it. Otherwise, you get this pattern of I'm going to override because I have to do it all the time just to get a bag of fluids. So that's a good takeaway. I do. I found one comment from the DEA in Tennessee that said, this is not against the nursing community. And I think maybe they meant that, but I think everybody was so obviously, emotionally distraught with this entire case. But I'm not sure that the healthcare community and not when I say that I mean, nurses and doctors and everyone, I'm not sure that they would agree. How do you feel about the DA saying that this is not against the nursing community? What are your thoughts on that? Well,
Dr. Stephanie Sanderson 17:16
I think I'm not really sure what the DA knows about health care. And I'm not sure that the DA can truly understand what health care workers have been through, in, in the last three years now. With the way that the pandemic has sort of affected health care workers in general, and so I feel like I don't know that was sort of cheeky in a way to say something like that, because it's, it's, it had a profound effect on me, I was, I was literally horrified. And I'm not even exaggerating, when I heard the that this nurse was going to be criminally charged. I just, it took my breath away, because of what I know, in healthcare. You know, when you've been a nurse for nearly 38 years of your life, and you've worked in an academic medical center for the majority of that time, you see things that that you will never unsee in your career, and you go through things that you will never forget. And to make a comment like that really almost added fuel to the fire because it is it is directed to the healthcare community. It's a very loud and very strange statement to be making, especially after what we've been through.
Adrianne Fugett 19:01
Yeah. Yeah, that brings me to another part of my notes I want to chat with you about so Becker's hospital review, and I can make sure that we post this article on the notes in this podcast, but they just recently posted an article that more than 100,000 nurses left the work force in 2021. And this was according to an analysis that was published in April 13 in Health Affairs, and now that we're seeing nurse Vaught’s criminal conviction for this medical error. What do you think this has, the DEA in Tennessee has accomplished? Are you worried that first of all we've got kind of the baby boomers, right, we've got our age group that's going to be retiring, so we're R&D going to have a huge exodus of health care workers, but are you worried about what this means moving forward? For nurses and doctors and real any provider?
Dr. Stephanie Sanderson 20:02
Yes, I am very worried about this. And I, I've done. I've been reviewing the literature since this case came up to kind of dive into what do people going into the profession? What do they know about the consequences of the profession? And what do they really understand getting ready to become a doctor or a nurse or a respiratory therapist or anybody who it is charged with the very, very complex care of patients. It's, it's very, it's rooted in or steeped in, like the possibilities for making mistakes all the time. And I think when most people decide they want to help someone, or they want to go into the profession, because they're going to help, and they're going to make a difference they are, but they are also at high risk for doing harm, unintended harm, and I don't think that I remember being taught when I was in nursing school that I could make a mistake so profound, that it would cost someone their life, and then then I would be in legal trouble. Nobody wants to go into a profession where they're going to end up in jail. And it almost seems like the consequences are not the same, or that they're different for different levels of, of if you're a doctor, you might not get punished severely. But if you're a nurse, I mean, what this says to me is, oh, you're going to get punished, especially on the there's another case out there about a doctor that was acquitted for prescribing inappropriate doses of fentanyl to patients. And that is on the on the back end of this huge case. And I think that again who was egregious? And was it was obvious, he, he's not going to jail, but why
Adrianne Fugett 22:29
you're not going to go to jail? That's a really valid and sobering point. And what advice would you give to nurses that are still fearful about reporting errors? Because we know that if as nurses, we don't report medication errors, that as leaders, we can't improve the systems with which we deliver care? So it does, this affects patients, right. So, but still, what do you do with your staff after this? And how are you guys navigating this?
Dr. Stephanie Sanderson 23:03
Well our hospital very shortly after the verdict was in, sent out of system wide emailed to address the fact that they were aware that nurses would probably be afraid, and to encourage us not to stop reporting errors and, and to sort of validated the fact that our organization really, really promotes the just culture model of managing errors. And that's something that that folks can also find a lot of information out on the internet about a just culture. Many healthcare organizations use that as a as a tool to help leaders navigate situations where nurses make mistakes, and how to coach them and console them.
Because again, they're second victims, the patient is harmed, but they are also harmed. I know that as a nurse, I've made multiple, multiple mistakes. I've made medication errors, I've made treatment errors. I've done the wrong thing to the wrong page. I've done that. I know that I have and I bet that I'm going to make more and I know that my nurses are going to make mistakes. And when they do make a mistake, what I try to do is to coach them, everybody needs a coach. It doesn't matter how long you've been doing something or how good you are. Okay, how can we do this better? or how did this happen? Tell me how this happened because maybe I can intervene. And this is a system problem. I try to look at it that way I try to these are not bad people, this might be a bad process. But if they're not telling me, okay, I made this error but so if I can share a recent situation to kind of drive this point home, I had a nurse make a very, very egregious heparin error and giving heparin could be life threatening, because an overdose of heparin can cause the hemorrhage it can cause strokes, head bleeds, it can cause all kinds of problems.
And when I found out about the mistake, what I did is went back to find out what was happening, what was the what were they doing before the mistake happened, and what happened was that there were two nurses taking care of a critically ill COVID patient who was just put on ECMO. And they were in a room in an isolation room. That was a negative pressure room, there was lots of noise, they were in full PPE wearing peppers. Someone was outside the door, telling them to give heparin he the person outside the room because they tried really hard not to open the doors. And once you were in a room, they tried to stay in the room until they didn't need to be in there anymore. So there was a nurse outside the door. mouthing to give 2000 units of heparin, the nurses in the room thought he said 10,000, you Oh, my goodness Heparin, they didn't double check that they didn't verify that they didn't wait for an order that said that, because they trusted the nurse giving them right directive. And two
Adrianne Fugett 27:06
and 10, behind a glass door looks the same. If you're reading Yes,
Dr. Stephanie Sanderson 27:11
it does. And if you're wearing a PAPR, and you're Yeah, hot, and the situation is very stressful. And so when I found out what was happening, I really, really sat down with myself to rehearse how I was going to address this because I was afraid that these nurses would deteriorate pretty rapidly if they knew that they had made this big error. And that, and that it could have caused this horrible harm in this patient who was already so incredibly sick. And so we sat down, and we had a very open dialogue about it. And I did not see it as like negligence, they could have done a few things differently. But in that moment, I gave them that grace, which they deserved, because they were in a very, very difficult situation. Now we talked about all the things they could have done to have avoided that. But neither one of those nurses quit. Neither one of those nurses called in sick for the next month, because they felt so bad about what had happened. And I believe that that was because we really worked hard to preserve their integrity over all of this.
Adrianne Fugett 28:38
nurses don't do well, when they've made an error that leads to someone's death. They right or harm, it's for harm. Yeah you've given us some really good tools. I liked what you said, about for hospitals, making sure that their override list only includes drugs that have high risk attached to them, because you don't want your staff to get used to overriding as a way of practicing. And I before we close up the recording, I do want to get some kind of silver lining and more positive takeaways from this event, because you touched on. You know how there's two victims, there's the patient and the caregiver, which in most cases is the nurse. And we know there was recently a nurse in California that shot herself in the ER of where she worked. And although we don't know all of the details, we do know that we're still coming off an environment of COVID where the healthcare workers are under just immense pressure that I'm pretty sure I couldn't have handled by work at the bedside. And so I'm really concerned about an alarming number of mental health issues and how we could end up with a health care system that we don't want and So this has been a really challenging conversation. And I really love the feedback that you've given to kind of some good silver lining takeaways. But are there any other positive takeaways that you want to share with organizations at the leadership level as well as with nurses before we end our podcast?
Dr. Stephanie Sanderson 30:24
Yeah, I think my biggest message is that leaders need to, to really, really be on the same planet, as their employees, and that they really need to be put themselves in their shoes. And, and, and understand the pressure and the and the circumstances that these nurses are in and work hard to remove some of the burden that we impose on nurses, and figure out better ways to do this work, because look at how far we've come. I think that there's only opportunity in all of this. And I think that if healthcare organizations were more committed to the employees, at the bedside doing this really hard work, we probably wouldn't have these problems. I'm not trying to say that all organizations are like this. But I think that we need to do a little bit of like, re-imagining how this how this could look in the future so that we don't lose any more of our workforce or create a situation where people don't want to become nurses or doctors or any, any health care provider.
Adrianne Fugett 31:55
Yeah, I agree. I can talk to you for hours about this. And we're a little over time. I just want to thank you and everybody, for listening to today's podcast, reimagining health care, a new dialog with health and safety leaders. Again, subscribe and share if you found value in this episode. If you want to participate as a guest, please send us an email at speakers@Medplace.com also follow Medplace on LinkedIn. And Dr. Sanderson. can people find you on LinkedIn if they have questions? All right, my friend. It's just such a pleasure. Again, thank you for your time and thank you for spending time with the listeners of Medplace podcast.
Dr. Stephanie Sanderson 32:37
My pleasure, as always.