Nurse found guilty in accidental injection death | Hacker News Reader

Nurse found guilty in accidental injection death

npr.org

16 pointsrudedogg9 comments

Given that her license was revoked, and there's no reason to believe she is going to continue practicing, I do question what possible remedy jail could possibly bring to the situation. It seems there is zero chance of this mistake being repeated, that she is genuinely remorseful, and that there was zero malice involved. And the level of deterrence at preventing addition death is probably negative, given that this conviction will make medical providers want to cover up accidents even more -- so there's really no good argument to be made for making an example of her.

That said I understand jail is also about punishment and eye for an eye. I hope she was only jailed upon wishes of the family of the deceased. To bring justice to a family that wishes this kind of justice, is the only way one can possibly justify the sentence.

Something happens to people when they do a job for a long time without incidents. They begin to think that the warmings are overblown. That the warming are a bother rather than an aid to help you do your job safely so you stop paying attention to them. This lady could have had 20 warming and still she would have skipped them without reading them. She was so sure she had the right medicine so to her they were just something to skip.

Her prison sentence is more a warning to all the nurses that are doing the same overrides. They need to pay attention since they will be punished if something goes wrong. It's a sad situation for all involved but making a example of some is common.

Our justice system works on punishing the guilty and serving a warning that if you are doing the same this is how you will be punished when caught. It's a way to reduce crime.

The medical world needs follow the aviation industry in not assigning blame to individuals after incidents unless they had reckless or malign intent.

People make mistakes. If your system relies on people not making mistakes then it is an unsafe system.

Did you read the part of the story about their horrible computerized drug dispenser? I'm amazed more people didn't die as a result. Prosecuting this nurse is among the most wrong-headed things I've seen all week.

My mom was a nurse and this is just another one of the unfair conditions nurses have to work under. Doctors think that nurses are idiots and expect them to blindly follow the doctor's orders, but if the doctor makes a mistake and gives the nurse bad instructions, the nurse is personally liable for it.

I think this is probably correct. If you are giving someone vecuronium, you better hope they are already on a ventilator. It's like accidentally pulling out a firearm pistol instead of a taser and shooting someone.

There are some details here about the technical/software aspect of this that are interesting: https://www.medpagetoday.com/special-reports/exclusives/9782...

> Prosecutors are expected to focus on how Vaught overrode several warnings from an electronic medicine cabinet. Vaught allegedly typed in "VE" for Versed, but when nothing came up, she hit an "override" that brought up more medications, according to court documents. She searched "VE" again and the cabinet produced the paralytic vecuronium.

> Vaught had to override at least five warnings or pop-ups alerting her to the fact that she was withdrawing a paralytic, prosecutors allege. She also allegedly did not recognize that midazolam is a liquid, while vecuronium is a powder that needs to be mixed into liquid.

> During a nursing board hearing last year, Vaught stated that overrides are part of normal operating procedures.

> "Overriding was something we did as part of our practice every day," she said, according to an NPR report. "You couldn't get a bag of fluids for a patient without using an override function."

I wonder why the proper medication wasn't in the list when the Nurse searched? It's UX/UI 101 that if you nag users constantly they'll ignore your warnings as well.

It does sound like the Nurse was driving on autopilot and skipped over several things that should have made her pause while preparing the medication though.

Nurses get warning fatigue. They get warned about everything all the time. Medical devices are always audibly alarming.

Engineers designing these machines should be required to shadow nurses for a few months.

It is sad that it has come to this, but the medical boards have not been effective at all.

If the professional medical orgs don't want outside oversight, they need to demonstrate some sort of competency.

They could learn a lot from the aviation industry.

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