Thread by @NurseJustinRN

#NurseTwitter like most of you, I've been reflecting on the #RaDondaVaught case. The only thing I'm emotional about is the loss of an innocent life. I think it is important to reflect on future practice implications now and take a long hard look at "just culture" 1/

First, we should examine two cases in the country that did not receive attention or support where a nurse was criminalized for fatal medication errors. It should be noted that this is a rare occurrence, but what is happening with RV has happened before 2/

Case A: In Madison, WI, a 16-year veteran nurse administered a lethal dose of an anesthetic (meant to be placed in the epidural line) and an antibiotic. The 16-year old laboring patient died. The nurse did not scan the med, check the med, and created an override in the Pyxis 3/

The nurse lost her license and faced criminal charges. This case occurred in 2006. No one supported the nurse, and the criminal charges against the nurse DID NOT IMPACT the practice of other nurses, nor did it corrupt "just culture" that term is already corrupt 4/

Case B: occurred in Denver, CO in 1996, when 3 nurses held accountable for the death of an infant, where PEN G was administered IV (in a large dose) but was meant to be IM. All three nurses were implicated and criminally charge. Again, this case did not change our practice. 5/

If you'd like to read more about this, you can review this case report published in the journal of nursing regulation. 6/
sciencedirect.com/science/articl…

These cases demonstrate some things we've all known for a long time 1) we are responsible for our actions 2) mistakes happen but gross negligence is another topic 3) none of these cases, including RV's case, will place nurses at increased risk. The RISK has always been there 7/

When we discuss "just culture" we imply that this means no accountability for negligence."Just culture," in this context, means that there is a safe space to admit and report errors, but it should be understood that the presence of a"just culture"does not negate accountability 8/

We can talk all day about system errors, but nurses have an important role in changing this--not for RaDonda, but for our patients. Don't blame the system, let's fix the system and hold systems accountable too. Here is how we can do this: 9/

1) make sure all open bins in automated medication dispensing systems are converted to closed-bin systems. 2) Mandate 5-rights training annually 3) Ensure scanners are in every area a patient might also be in 4) redefine "just culture" placing accountability at the top 10/

Let's not just talk about it, let's do this. Let's do this in honor of the person who died. Let's focus not on RaDonda, but on how to fix this. I wrote the title of a bill (needs work) and have much more to add. If anyone wants to join me in holding 11/

hospitals and technology companies accountable (as much as nurses are held accountable), let me know. Let's introduce legislation and stay on their jugulars /end