This months episode of “News you can Use” on HealthcareNOWRadio features news from the month of March 2022
As I did last month I am talking to Craig Joseph, MD (@CraigJoseph) Chief Medical Officer at Nordic Consulting Partners. We review the recent in person events we both attended in Florida this past month, both coming away with a positive view of the experience and invigorated to be back in person and interacting with our colleagues, friends and healthcare teams.
Criminalizing Medical Malpractice
The Majority of our time was spent discussing the recent news of the RaDonda Vaught, a former nurse criminally prosecuted for a fatal drug error in 2017 who was convicted of gross neglect of an impaired adult and negligent homicide. She now faces yeast in prison based on the current sentencing guidelines
As Dr Jayne detailed in her blog:
The only thing being discussed in the virtual physician lounge this weekend was the trial of Tennessee nurse RaDonda Vaught, who was found guilty of criminally negligent homicide following a medication error
Listen in to hear a detailed breakdown of the mistake made on the floor by this nurse that centered on entering 2 letters ot find the drug she needed, the reason why the drug she wanted did not even show up in the list (hint – drugs have 2 names – Tylenol or paracetamol and acetaminophen for example). And hear the background to why this was even possible and happened and what might contribute to this occurring again and why this action could cause more errors to be made
You can read more about the series here and the concept of keeping up with innovating in healthcare. Please send me your suggestions on topics you’d like to see covered. You can reach out direct via the contact form on my website, send me a message on LinkedIn or on my Facebook page (DrNickvT), or on Twitter tagging me (@DrNic1) and #TheIncrementalist or you can click this link to generate a ready-made tweet to fill in.
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Raw Transcript
Nick van Terheyden
And today as I am each and every month, I’m delighted to be joined by Dr. Craig Joseph. He’s the chief medical officer at Nordic consulting partners, Craig, thanks for joining me today
Craig Joseph
for having me once again.
Nick van Terheyden
So, another month in the books, I think things are changing slightly as evidenced by attendance at two conferences in person, right. You and I were both at a couple of healthcare conferences.
Craig Joseph
Yeah, bogies open Florida, actually one in Miami and one in Orlando. And they it was, it was great. I thought it was great. I was very excited to see people in the flesh again, and wasn’t the first time that I think either of us attended conferences. Was it your first time?
Nick van Terheyden
Oh, no, no, no, no, I’m so used to be a regular, I don’t think I’ll be quite as regular as I used to be. I’m just gonna say that now. Actually, now
Craig Joseph
I’m thinking we recorded an episode about nine months ago at a conference. And so that was a silly question. Now that I know that I think about it. But that there were certainly more people at this than others. And I thought it was great to exchange information and, and learn new things from my colleagues. And I’m glad that COVID is 100% completely over. And we’ll never have to deal with it in any or any rep or questions ever again. And we’ll never speak of it again. I’m glad. I’m glad that that’s the case.
Nick van Terheyden
Yeah. And we know, as usual, that that’s not the case based on the fact that your lips are moving. That’s not true. Oh, ouch. So what my my highlights from that, let’s say, you know, so let’s pick off. So it’s been, we did go to that conference in between, but it wasn’t really a full on conference, because we still had to wear masks in both of these instances, masking was not required. I want to say that the positive or the big positive for me was the human interaction. And what I found with the mask conference was that that wasn’t as possible or even as effective. So I was delighted to see and interact with people face to face to recognize people. I saw folks that I hadn’t seen in a long time. And it was a delight. I saw people and met people that I would never have met and would never have connected with were it not for this conference and those chance interactions that you end up having courtesy of social engagements happen to be next to say, you know, all of these random examples that, you know, who knows what they turn into, ultimately, and that, for me was the big positive. I think they were fairly vibrant activities. They did a decent job with sort of social and, you know, other things, I would say that my conference muscles had atrophied. Significantly, I was a wreck physical from all of this. And, you know, it reminded me of all of the reasons I hated being on booths, staffing them, because it was all standing. In fact, I used to work for a company that specifically banned any kind of seating because it looked unprofessional to be sitting down, which, in hindsight, will explain all of the back pain and challenges that I’ve heard, but I would say all in all well worth attending and well worthwhile.
Craig Joseph
Yeah, I agree. And it’s much easier to recognize people without a face mask, and there were a few I would say what would you say maybe 5% or 10% of people who are wearing masks some? Maybe less than that? I don’t know. Some some folks wore them and, and of course we don’t know. Some people are weary of the science. Some people have immunocompromised, they’re immunocompromised or they’ve got immunocompromised friends and family and so lots of reasons for for people to remain masked up, then that’s completely appropriate. Curiously, both conferences even though they were days apart, have different requirements. So the state of Florida as I understand it, I’m not a lawyer. But the state of Florida has banned private companies and organizations from requiring vaccination and I think that that’s still bouncing around the courts but so so either conference could require you to be vaccinated but what they could do is require you to be tested before you Before you get it. And so that was the one of them was much more aggressive. I didn’t really feel that there was a big difference in the in the attendees, I think mostly everyone was comfortable that the almost everyone was either vaccinated or tested on that day. So one of them did require that if you if you didn’t prove that you were vaccinated, that you had to be tested daily, in the morning, and hard to hard to enforce. But I think it worked and, you know, kind of leads, there’s just a ton of questions about how did that make us feel safer? based on science, or just made us feel safer? You know, kind of warm and warm and fuzzies? And that, I’m not exactly sure.
Nick van Terheyden
Yeah, it’s interesting. They were they were different, because certainly based on my experience, and I had the same vaccine status that I had in both instances, but in the former I was required to test when I arrived. But in the latter, I was not, even though I was approved my vaccination status voluntarily, because I couldn’t be demanded of it. So obviously approached it differently. You know, the, the masking thing is interesting. And I like you noticed it, I would say it was lower than 5%. But you know, immaterial and I had no issues, but it was a bit like the question I always have when somebody dies, I want to know what they died of. I think that’s a frequent sort of request. And I’ve told my family when I die, please publish the reason why I died in the notification, because I know that I always wanted to do and I felt like that with the masking and it was not a pejorative question. I just wanted to know, I wanted to understand it was part of the sort of, you know, process. Not once did I ever ask the question or even, you know, intimate because I felt that would be sort of an excessive imposition, but there’s a part of me wanted to, you know, could they were the little wristbands that said, this is why I’m doing it. I’m sure that’s completely impractical. But it was one of my thoughts.
Craig Joseph
Yeah. I, yeah, I agree. You know, they did have little wristbands, curiously, that were supposed to tell people that you were encountering how you felt about close contact, like our hugs, okay. Or is it a fist bump? Or is it No touching whatsoever? And I found very quickly that no one either I had the poser. Okay, the green one, I think it was a green, yellow and a red one. And most people can just figure it out without all of that, right. Like they didn’t even look, there are times where I put my hand out to shake someone’s hand and that they gave me their elbow back. And so yeah, I got that I got that message. And, and I think, again, you know, you and I have been a big proponent of, hey, we need to meet people where they are. And sometimes they’re concerned for scientific reasons. And sometimes they’re concerned for not scientific reasons. And either way, it’s okay. Right. You know, I’ve heard some people talking about going on airplanes, that it’s likely that in the US will not be required to wear a mask soon on an airplane. But there a lot of people are like, You know what, I think I might continue to wear a mask. Oftentimes, people get sick after coming on airplanes, you know, in the pre pandemic kinds, and, oh, I’m sure I got this cold because this guy next to me was, was hacking up along and you know that again, how do you know for sure, I don’t know. But it might be easy. Well, I find it very easy and not difficult to wear a surgical mask. And so I I don’t know what I’m going to do. I think for a while I’ll probably continue to wear a mask on airplanes. And also when I’m in large crowds, I know
Nick van Terheyden
you’re dying. You and I are at different ends of the spectrum I’m I ripped that thing of my risk tolerance is high. And my capacity or tolerance or you know, just acceptance of it is not and it’s the sweat, you know, and it was one of the reasons why I didn’t want to do surgery. God I hated those things. I constant struggle with them. So different different sort of approaches.
Craig Joseph
Yeah. So I’m right, you’re wrong. But let’s move on. Loss of words.
Nick van Terheyden
I’m, I’m always at a loss for words sometimes talking to you.
Craig Joseph
Well, I bet you’re not going to be at a loss of words about our next topic.
Nick van Terheyden
No. So let’s set this up. This is a biggie. I think there’s lots to talk about. So Redonda vault, I hope I did justice to her name, she is the nurse who has just recently been found guilty. In the accidental injection of a 75 year old patient that died, she was found or convicted of gross neglect. And negligent homicide. These are terms that I’m not fully familiar with, but they are significant they come with jail time. She was a nurse working at Vanderbilt. And she picked up or picked the an incorrect medication from an I’m I’m gonna I think it was a Pyxis system. I don’t think it matters too much which one but it’s it’s not an automated system per se use, you have to interact with it. But it’s a secured lockbox that you enter codes and have to authenticate to get the drugs out. That’s my best sort of understanding and description. And she was looking for one thing, but grabbed or obtained another and gave it to this patient. And the patient subsequently died. And she has been convicted of a criminal intent. And I suspect unless the judge or whoever carries out the sentencing finds differently, she is going to jail
Craig Joseph
making a lot of news in medical circles, and I suspect precious little news outside of the Nashville area. But it’s it’s it’s, I would say jaw dropping. And so this is you know, we’re we this is criminalizing medical malpractice essentially. Now, the argument that the prosecutors gave is that no, no, you know, we all make mistakes, we accept that. But this nurse made multiple, multiple mistakes had multiple opportunities to correct. Correct the the problem that she was creating, which is true. However, I think most nurses and and and clinicians and everyone else that kind of deals with people’s lives, understand that she was put in a place that was very bad. We’re, again, we’re talking about Vanderbilt, nationally acclaimed institution. And she was put into she essentially was dropped into a system that was there too, that couldn’t support her. And so she was so that the the, you called it a Pyxis, which is a brand name, it’s a medication cabinet, I think is a more generic thing. And ideally, these are for meds that are frequently used on the unit that you’re that you’re the nurse for, and you get an order. And when you identify when you go to this cabinet and say, Hey, I’m Nurse Smith, I’m here to get medication for patient Jones, the medical the cabinet knows, because it’s got access to electronic health record and all of the orders, what what medications that might be infected, often it’s down to just one and it pops open the right cabinet so that you get the you only are able to choose from one or a few medications, in this case that that connection was not working. And the only way to get medications out was to do what they call an override, which is where you’re bypassing the security systems that are in place to prevent this from happening. And sometimes you do need to do an override if a patient is trying to die in front of you. And a doctor is yelling out orders during a code or resuscitation, and you don’t have the crash cart or the right equipment in front of you. Sometimes you do need to run and you just need to get the med that you just need to get. And you don’t have time for someone to go into the computer and log on and find the patient put the orders in. And that that makes sense. That’s a high risk. It’s a high risk environment, but that happens. And so it’s not unheard of that you would do one of these overrides, but they were doing overrides based on nursing testimony for almost every patient because the systems that we’re supposed to be talking to each other. We’re not and she typed in, she needed to give a medication called the generic name was medazepam. But the brand name is birth said. And so most people call the first set even though the generic is like I said in the dazzling and she typed in V and R I think she typed in ve and it started the system that she was the box started to show her medications that were available beginning with B E. And not one of them was for upset, because it was only showing generic names. And she picked back Iranian, which is a paralyzing agent. And we paralyzed patients when they’re, they’re going to be intubated, you know, we’re gonna connect them to a ventilator, and we don’t want them fighting against the ventilator. So it’s a common commonly used medicine. But, you know, if you’re going to be paralyzed by a medication, then you’re going to need very, very, very, very close observation and support. And that’s where some of this, you know, this kind of came in. So she picked a she picked the medication that the cabinet gave her, because she couldn’t find her said she thought she was getting her sad, but she didn’t get percent. And then when she had the, when she had the cabinet open, the medication had, you know, was labeled, and she didn’t look at those labels.
Nick van Terheyden
For those of you just joining, I’m Dr. Nick the incrementalist today I’m talking to Craig Joseph, he’s the Chief Medical Officer at Nordic consulting partners joins me each and every month, the news you can use, we were just talking about the nurse at Vanderbilt, Craig has done a excellent job of getting right down into the detail of what goes on and what actually happened in terms of this nurse. And that experience. She was looking for a anxiolytic to relieve the patient’s anxiety going into, I believe an MRI, if I recall, and picked another medication that started with the same letters using an override. That paralyzes you. And for a deeper context, that means you literally can’t move, and that includes your lungs. And that’s what we use in anesthesia or anesthesia, anesthetics as I would say. So why would anybody make that kind of decision? Or make that? I mean, you know, for folks outside of healthcare, they’re probably listening to this and going well, that’s how could you possibly make that mistake.
Craig Joseph
And that’s where we’re talking about a safe system, or lack thereof, right. So it, you know, ideally, it should be impossible, impossible for a nurse or doctor to make such a mistake. That’s that’s the goal that we’re we’re we’re looking. So if you didn’t do an override, and if we had all the systems in place, and again, it wasn’t a choice to do an override there was the systems weren’t talking to one another. Ideally, there would be multiple checkpoints, that would be technology driven. So for instance, medication barcode scanning. So under normal circumstances, which were not operating at this hospital at this time, under normal circumstances, in most hospitals, in most parts, many parts of the world, you would take out a medication, you would go to the to the machine, by the way, and let’s just be clear these machines exists. So that nurses and it’s, again, I’m talking about nurses, because it’s mostly nurses that are administering these medications, doctors order them, but the nurses give them instead of having every medication that the pharmacy owns, sitting there waiting for the nurse to open up, they put them in small boxes. And so if we know that you’re looking for said medazepam, only one little box will open potentially with two or three different medication choices. So now it’s impossible to choose that, that paralyzing agent, because you just can’t even get to it because that box is locked because the machine knows that you’re looking for this patient’s meds, and the one you’re looking for is only in box 42. That’s the only box you get to look at. The next step normally that would have happened is that there’s a barcode on the medication on the little ampule that the nurse is drawing the medication out through the syringe. And the nurse would take that that ampule back to the bedside. And they would scan the patient’s wristband which is connected physically to the patient that identifies the patient. And then they would take the same scanner it’s the same barcode scanner you see at the grocery store. And they would scan the the ampule and the computer would know that there are five rights have now been achieved, right and I always forget one of the rights but right patient right medication, right. Routes meaning is it oral or is it ID or is it from us? I think right time, and there’s one other, right, which I can never remember. And so the all of these are achieved, because the computer knows the time and the dose that you’ve taken out the size of that ampule. And, and the patient. And that would have been, it would have would have been like a crazy, it would have gone off. If she had tried to scan the barcode of the of the paralyzing agent, she couldn’t, because there was no scanner work at the time. And so all of these things are kind of stacked up against against her. And the system was not there to protect her. And she did not. She missed multiple cues. And here’s, you know, where I understand, I understand where some of the prosecution and some of the other folks that support this prosecution are coming from. She had multiple opportunities, the ampule itself had a big red label on it, saying something like, you know, paralyzing agent. So you know, what you’re getting into plus the, as I understand that the medication she wanted was a liquid, and the smell is a powder. So there were things that under ideal circumstances, she should have seen. All of that set, all of that set. When you when you criminally prosecute people for making mistakes, terrible, horrible mistakes, still, you are sending a message to everyone else around around them, do not, if you make a mistake, keep it to yourself. Don’t try to identify don’t go public with it, don’t admit to it. Because you might be going to jail. And that that is a that is that has a very dangerous precedent that we’ve set here. It’s you know, it’s
Nick van Terheyden
chilling, it is truly chilling. Because if we are to achieve the Six Sigma safety, that we aspire to, that we have an airlines and everybody expects, because they don’t expect to get onto an aircraft and, you know, lose their life, which you know, used to happen many years ago, but they focused on a no fault approach. And it’s still imperfect, as we see, you know, outside of that, we don’t do a good job in healthcare. And this particular nurse, let’s be clear, as best as we know, from the details that have been shared, did all of the right things, and, and alerted as soon as she understood, provided the details has gone through all of the process with her own professional societies and so forth. Trying and, you know, has been clear about how devastated she is, from a personal standpoint, she can’t recover from this, that patient can’t, and ultimately, is being prosecuted and sent to jail. That chilling effect is so completely unacceptable to me. And I understand the whole thing of you know, multiple overrides. But if you’ve ever had the pop ups, and I’m trying to think of you know, the example, let me pick you loads, you know, the the things we click through to say, Yes, I agree with your terms and conditions that are 16 pages, everybody on this, listening to this podcast will have clicked those and not read them yet. You know, they provide whatever we all blast through. And in this particular instance, she had to because that was the status of the technology and the requirements, and indeed the problem that they were having, because they weren’t able to treat patients because these pop ups and alerts were happening and had not been filtered out. We hear about alert fatigue. So that’s not to excuse that she didn’t do and make a mistake. She did all of the right things appropriately subsequently, and is now being punished. And in this day and age. I just at my heart bleeds for her as it does for the family that lost this particular patient, but I just think it is entirely and utterly unacceptable.
Craig Joseph
i It’s dumb. It’s it’s I don’t know how you can look at any doctor, nurse pharmacist therapist in the eyes. If we continue to do these things and say, Listen, you’re human, if you make a mistake, even if it’s a close call. You need to tell us, right? That’s how that’s one of the major things that we’ve seen in the airline industry, right? It’s not just when bad things happen. It’s when bad things all Tap. That’s really where you learn lessons. And so Angie, raise your hand say, Listen, I almost did this thing. That was horrible. But I caught myself because of this or someone else caught it because of that. And then that teaches all of us. And we all learn from those things and, and yeah,
Nick van Terheyden
unacceptable
Craig Joseph
criminalizing This makes all of that almost impossible to look at someone and say, Listen, we need, we need you to come forward, even if even if there’s no patient harm, because you found it at the last second, but it almost happened. That’s unlikely to happen. That is probably going to just be hidden away. And we as or you know, as a group are not going to learn about it can’t can’t put methods in to to improving it and making it less likely that something bad’s gonna happen. It’s just, it’s horrible all around.
Nick van Terheyden
Yep. I think we’re in complete violent agreement with regards to that for all of the safety reasons that you described and the opportunities for improving healthcare. Unfortunately, as we have each and every week, we’ve run out of time. So it just remains for me to thank you, Craig, for joining me on the show today. Thanks very much.
