Should Nurses Who Make Medication Errors Be Charged With Homicide?

This appears to be an emerging trend in health care. Recent cases involving serious medication errors, led to charges of homicide. This is definitely a deterrent as far as attracting people to an already over-burdened health care system.

This post describes some general thoughts based on what I have read about these cases, and is just opinion, not related to anything other than my own experiences and observations over the years.

Most experienced nurses know that anyone can make a mistake. There are many contributing factors to the medical errors made in hospitals and various facilities. A huge part of it is trying to keep up with an unreasonable work load. This causes people to take multiple short cuts, including not taking the time to double check or look something up.

There are understandable mistakes, and there are mistakes that leave you wondering how on earth something like that could happen. For example, in an emergency situation, a person might answer an emergency call bell, and start an IV, using a bag of IV fluid that is hanging on an IV pole beside the patient.

The nurse may have been called to help in a dire emergency, and started the IV without realizing an anesthetic drug had been added to the bag. The bag may have been set up by an anesthetist, in anticipation of needing to intubate. Then he/she gets distracted, and leaves the IV pole and bag hanging beside the patient. This means it is a compounded error, not simply the fault of the nurse. We already know who is most likely to get the brunt of the blame though.

In such a case, the nurse who ran into the room and started the IV, may not have seen or read the label. Or the label may be scrawled, and she assumed it was something else. It is very common to add the drug Syntocinon to a bag of IV fluid for obstetrical emergencies, specifically postpartum bleeds. In fact, it would be an assumption since it is the most commonly used drug post delivery.

The nurse’s error would be to have assumed what was in the bag, without double checking. It is because it is what you would expect to be in the bag in that situation. She may have been called into similar situations in the past, and started the IV, when the drug she expected to be in the bag, was in the bag, and all was well. If it was not clearly labelled, and just had a big S and a scrawl using a black felt pen, the nurse could inadvertently give a bolus of an anesthetic drug to a maternity patient who is not only bleeding profusely, but is also not intubated. Once the drug is given, the patient is fully aware, but cannot breathe.

Another potential for errors, is in doing IV drug calculations. Although nurses do not have to do as many drug calculations as we did in the past, drug calculations are rife with errors. Some people cannot do simple math. It was not uncommon for certain nurses to miss a zero, and end up giving ten times the dose. In other cases, when you heard about or evaluated some of the errors made, you could not even figure out how they made such a colossal error in calculation. This is especially dangerous with neonates and infants.

I also think it is too much to expect a staff nurse to teach, mentor, or orient students, unless she is a qualified instructor, who is given the time it takes to watch over, and explain things to the newcomers. Mistakes are often made because the nurse is struggling to keep up with her own tasks, and may find a student, or the expectation to do staff orientations, to be an added stress and distraction.

Some nurses thrive on teaching, and others do not. Some are very organized and efficient. Others are disorganized and chaotic. There is a wide range of personality types. There is also an old school element that crops up, and is seen as archaic.

The bulk of errors involve oral medications, and often don’t do much harm. Now that the pharmaceutical companies calculate dosages, and set up the med carts so they are accessed by the primary care nurse, and individual medications are set up to be dispensed at the specified times – why would there still be oral medication errors? I seriously wonder if all the new and improved controls have actually improved things.

In fact, the errors seem to be worse and more catastrophic than ever. Is it because the new system of dispensing is faulty? Is it because there are so many glitches, they need an over ride just to give someone a Tylenol? We used to stand and pour the medications, taking each bottle of stock pills off a shelf, and adding it to the little cup of pills with just a med card in a slot with the patient’s name and room number. It was old fashioned, but it seemed to work.

After that method went out of style, they invented blister packs. In this case, the pills were on large cards, on big flip racks, arranged by patient name, and bed numbers. The nurse would punch out the pills for each person into a little cup, hand them out, observe the patient taking the pills, and then carry on to the next patient. What could be simpler?

It’s not so much the blister packs, or the medication dispensing carts, with a code to punch in the nurse’s ID when removing medications that leads to errors. The problem seems to be the glitches in the system, and the nurse’s inclination to over ride the system when she is in a rush.

There are mistakes that make you wonder how on earth it could happen. But to be charged with homicide, is enough to put the fear of God into a person. Lives can be destroyed in a matter of seconds.

To evaluate the recent cases that happened in the US, while trying to be open minded about the basic practices leading up to the errors: In the RaDonda Vaught case, she chose to over ride the medication dispensary checks and balances, likely because she was in a rush. Or it may have been a common practice in the facility, due to the hassle of accessing prn medications. It is not uncommon to have trouble finding what you are looking for, especially for new or causal staff. PRN means to give a drug when necessary, usually for pain or agitation.

When a patient is admitted, they get their medications set up by pharmacy. But in the case of one time doses, or prn medications for an outpatient or ER patient, the medication is typically taken from ward stock. In this fatal case, she took out the wrong medication called Vecuronium, which is an anesthetic paralytic drug, instead of the drug she was supposed to give called Versed, which is a benzodiazepine or tranquilizer, commonly used to relax and sedate a person.

The drug was also labeled in red to indicate it was a paralytic, but she must not have noticed the warning on the label. Or if she had minimal experience with the drugs, she might have thought Versed was an anesthetic drug, and perhaps correlated it as being a generic name. Sometimes Versed is used in conscious sedations, so she may have been inexperienced in her knowledge of the drugs, and assumed that Versed might be labelled as such. Versed can slow the respirations, but it certainly does not paralyze the muscles of the diaphragm. So she did miss some key warning signs.

Part of the problem in nursing education, is the number of names a drug can be known as. The nurse might be confused by the wide range of names used for the same drug. She might make fatal assumptions. Although it is difficult for most of us to put ourselves in her shoes, we can see how a fast-paced, highly complex system can go awry.

The nurse in question gave a patient who was anxious about going through a CT scan, a potent anesthetic drug, as opposed to a minor tranquilizer. After giving the paralytic drug, she did not go back and check on her patient. It would have probably been too late, even if she did check her within fifteen minutes, because Vecuronium paralyses the muscles of the diaphragm so the patient cannot breathe. She would have needed to be intubated immediately. She could have been saved if someone had the presence of mind to manage her airway with a bag and mask, until they were able to get her intubated.

The explanation of medical errors being like the lining up of the holes in Swiss cheese, with numerous factors or mistakes, one after another, that led to a tragic outcome for the patient, seems to apply to these cases. The nurse did admit her mistakes, and has shown remorse. Clearly it was not an intentional error. As a consequence, she was sentenced to three years probation, and cannot work as a nurse again.

In another recent case in the US, a nurse was charged with homicide for giving an agitated patient a drug (again it was Versed aka Midazolam) to sedate the patient. This is a different situation. In this case, she was assigned to help with or take care of a 97 year old patient who was difficult to manage, confused and distressed.

The nurse called the GP for an order to sedate the patient, and the GP refused to give an order. She then asked a nurse practitioner for the order, and was refused again. Some of the nurse comments made on FB attributed the refusal to give an order, is because often the elderly do not tolerate benzodiazepine drugs well, and/or the possibility that the patient was being monitored for a head injury due to a previous fall.

However, the use of benzodiazepines in LTC is very high regardless. In fact, the growth in the use of benzos in LTC has grown exponentially since covid started, and they were overused prior to covid. So in this case, it is rather difficult to understand why the GP or NP did not assess the patient, and give appropriate orders.

This one seems to be a case of medical ethics, and power struggles. The nurse, being unable to get the order to settle the patient, took matters into her own hands, quite literally. In order to get access to the medication without an order, she went and took it out of the med cart under a different patient name. She somewhat surreptitiously drew up 2 mg. of Versed and went and gave it to the agitated patient.

She drew attention to the fact she was giving him a drug by claiming to be flushing his IV, yet it was noted she was using a different size syringe than one normally uses to flush IVs. When questioned about it, she replied that she gave him “something special”. In addition, the patient calmed down considerably after she gave the two mg. of Versed.

After that, she went and asked another nurse to watch her waste the Versed that she claimed to draw up for the previous patient. She told her colleague the patient had requested it, and then refused it. She did this as a cover to explain why the other patient did not receive the drug, even though it had been dispensed. She must have had the witness watch her discard normal saline, or possibly the unused portion of what was dispensed. It was all rather cagey by the sounds of things. It is hard to understand why she took such a chance, and placed both the patient and herself at risk. Not to excuse what she did, but she must have been fed up with trying to manage him.

One of the supposed safeguards and standard medication rules in nursing, is that certain drugs, namely narcotics, must be witnessed and co-signed, if they are wasted. So once again, we can see where this nurse did a series of things to get her self into hot water. But was it homicide?

As it turned out, the patient was fed sometime after the drug was administered, then aspirated food, and unfortunately died five days later. After he was sedated, he should have been put to bed and turned on his side, never mind feeding him. But hindsight has little benefit, especially when what he did receive was not charted, because there was no order to give it legitimately. So anyone called in to evaluate his change of condition, would not have had a clue what caused him to aspirate. When the chart was checked, there would not have been any indication that the medication had been given to him.

The biggest question that came to mind for me, is “what if she did get the order as requested”? It would be a non event. After all, it is not uncommon for 97 year old patients to die. He may have aspirated and died anyway. He may have had a brain bleed. Who knows?

The real issue is why there was such a disconnect between the nurse’s judgement, her actions, and the outcome? If she really was trying to kill him, she could have used any number of other drugs like insulin or a cardiac drug. It sounds like she had justified in her own mind that he needed this medication, and did not accept her role as being the one to administer, not order the medication. She was dishonest, but yet somewhat brazen as well.

To give an alternative view on this incident, although it is certainly not something to condone, we still have to look at the Swiss cheese type shortfalls. Personally, when someone was extremely distressed and out of control, I would hound the GP to come and assess the patient, and give some orders to alleviate the distress. Sometimes to get an order, a nurse has to go through a few hoops, and be persistent.

Many times, there is a power struggle between doctors and nurses. Certain doctors over medicate, and certain others will not give an order to sedate a patient, even if they are palliative and in a lot of pain. One thing for certain, is that many health care professionals do not realize when a patient transitions from being a LTC or acute care patient, to becoming palliative. There tends to be more mercy, and comfort measures for palliative patients.

By all means, it is awful to sedate the elderly just to keep them from making demands. In addition, there is a long list of medications that should not be used for chronic conditions in the older population. The use of antipsychotics for instance, is a nasty trend. Personally I believe the poly pharmaceuticals in LTC does far more harm than good.

But – when a person transitions to palliative, and/or is showing signs of severe distress and agitation – shouldn’t they be given something to alleviate their distress? She had no right to take matters into her own hands, but it does sound like the GP and nurse practitioner who withheld the orders, may not have done a proper assessment.

There is a gap in recognizing what is manageable and what is unmanageable. The nurse, being the one who has to do the direct patient care, seeks solutions or cuts corners. Right or wrong, that is what happens.

In fact it seems like the more controls they have put into the medication administration systems, the worse it becomes. Nurses quickly learn to over ride the system. Making a habit of doing so – is bound to lead to tragic outcomes.

One of the obvious problems is the workload. It is beyond the criteria contained within the standards of practice. Therefore you have the standards, and various policies versus reality.

A blanket defence to cover all nursing errors, is not feasible or desirable, because some of them are pretty outrageous. Most nurses do not make intentional mistakes, or over ride several checks and balances to get something done. So the mistakes or bad judgement of a few, should not taint the rest.

Another recent case reported in the news, involved a rookie nurse crushing up oral medications and putting them into the IV. It’s hard to even imagine how she managed to do that. Apparently she did not make it to first base in her critical thinking skills. Such mistakes, hopefully – are few and far between.

The number of mistakes made, including the even greater number of unreported mistakes, does warrant an overhaul. First of all, there are way too many names for one drug. They vary from generic names, to the trade names, and often have overlapping similarities to the names of other classes of drugs.

To give an example, a couple of OTC meds people might be familiar with; Gravol has the generic name dimenhydrinate, and Benadryl has the generic name diphenhydramine. You can see how a person might become confused, if she is looking at different drugs with very similar names, and often a multitude of different brand names. That is one of the problems contributing to medication errors.

Another contributing factor is the need to over ride, or the practice of doing so to save time. This is a responsibility of the facility if it is common practice.

Another key contributor to making errors is the attitude or expectation that nurses and doctors should be equipped and knowledgeable in all circumstances. It is difficult to admit to not knowing what you are doing. The old adage “fake it til you make it” is a part of the system, like it or not.

Back in the sixties and early seventies, nurses did about one third of their education in clinical practice at the bedsides. It got to the point where student nurses where being exploited as cheap labour. This was seen as undermining the profession, and not the best use of the educational dollars. Nursing education became increasingly theoretical and academic, with less and less time spent doing direct patient care.

The problem is, direct patient care involves all kinds of intricate procedures, not just a knowledge of medication, but things that you need to know. It might be sterile technique in accessing central lines, or something as small as which way to turn a three way stopcock. There are many things a nurse must do that can be lethal if she does not know what she is doing.

From a nurse’s perspective, always err on the side of caution. The time it takes to double check something is of far less consequence than getting charged with murder. Always get an order. It is not uncommon for nurses in remote and rural areas, to give a drug to a patient in the middle of the night, so they don’t have to wake the doctor on call.

Then typically the nurse would get a “cover order” in the morning, and if all was well, the doctor would give the order, and graciously thank her for not calling him. This may not be a common practice in the US, but it certainly has been a common practice in Canada.

My view on it was to always get the order, never mind taking such chances. For what? So you don’t wake the doctor up, because he might be snarky and miserable? Too bad. He/she is on call for a reason, and you would be dumb to assume they would give you a cover order if things went sideways.

From a patient’s perspective, know what you are being given. Ideally all patients should have an advocate, or family member at their bedside to help oversee their care, and to question anything that seems off. No one should administer a drug without telling the patient what it is for. If the patient is concerned, withhold it, double check, explain it, and call the doctor if it is not clear. It is also important to let the patient know they have a right to refuse it. If you act in their best interests and pay attention to their concerns, you are far less likely to make a mistake. In fact, if you take heed to even the slightest discrepancy, it may protect both patient and nurse from making a fatal error.

Overall, if an organization has multiple medication errors, they need to seriously evaluate the system. Yes professionals do need to take a certain amount of personal responsibility, especially if they veer off acceptable standards. But it is a systemic problem, if there is not sufficient time or resources to cover for inexperience, and making exceptions to the rule.

The bravado, and the expectation to be cool as a cucumber under duress, as a demonstration of competency, is not a good thing to cultivate. The systems are overloading health care workers. It has been going on for years.

Without a doubt, the addition of all the covid protocols, PPE, and added stressors, have precariously overloaded an already broken system. Most nurses are appalled at the thought of making a serious error. They live in fear of getting thrown into a situation they do not know how to handle, and therefore are vulnerable to making an error.

Perhaps the biggest contributing factors when it comes to medication errors, is fatigue, stress, and burn-out. A person can easily be legally impaired due to lack of sleep, constantly changing shifts – often being awake for twenty four hours at a time. This is far more common than people realize. If a nurse does two twelve-hour day shifts, followed by two twelve-hour night shifts, it means when switching from days to nights, she is working a night shift with just a nap. Keep in mind that many nurses also have small children to care for during those switchover days.

How many people could function with full cognitive faculties and alertness for a twelve hour night shift without sleep? Yet that is the norm and expectation in nursing. You do the two day shifts, and then try to get a nap in on the day you switch to nights. Unless a nurse takes sleeping pills, it is unlikely she can sleep for eight hours during the day, when for the previous days, she was awake and working during the day.

On a practical level, all medication carts and med rooms should have mounted magnifiers, and light loupes, to be able to clearly see the labels, warnings, and print on a medication vial. One of the things I distinctly remember as a young nurse, was being asked by older nurses, to check what the fine print said on the medication vials.

The importance of accurate charting cannot be stressed enough. The chart is the legal document, and is what is used if there is a court case, or investigation. If a nurse forgets to chart something she did, she cannot verify whether she did it or not. Charting is often neglected because patient care is a priority, but nurses should stand firm, and get their charting done, even if it involves overtime pay.

But the idea of being charged with homicide for mistakes, or criminalized for unfavourable patient outcomes, brings things to a whole new level of stress in the profession. I think this type of trend will increase the mass exodus from the profession, and also increase the trepidation in entering the profession.

For those of us who have worked in the role of an RN, and know how crazy busy it can be, we are just thankful not to have to endure the covid trials. I like many others, am so glad to be out of the profession. What a fiasco. They have my sympathy, and let’s hope the homicide charges are few and far between.

As far as mistakes go, in all honesty, every retired nurse, and all experienced nurses – have witnessed some humdingers!

Copyright Valerie J. Hayes and Quiet West (2022). Unauthorised use and/or duplication of this material without express and written permission from this blog’s author/owner is strictly prohibited. Excerpts and links may be used, provided that full and clear credit is given to Valerie J. Hayes and Quiet West with appropriate and specific direction to the original content.