By now, most nurses have heard about the case of RaDonda Vaught, a nurse found guilty of criminal charges – neglect and negligent homicide – after a 2017 fatal medication error.
Details of the Incident
On December 26, 2017, Vaught was caring for a 75-year-old patient at Vanderbilt University Medical Center in the Neuro Intensive Care Unit. According to reports
, Vaught was the Help-all nurse and had an orientee working with her during the shift. Several red flags are documented that led to the administration of vecuronium, a paralytic, rather than Versed (generic name, midazolam), a sedative that had been ordered to be given prior to a swallow study:
- The medication was not in the patient’s profile in the medication dispensing machine.
- Five warnings appeared during the machine override process. (During a testimony before the nursing board in 2020, Vaught testified that at the time of the incident, technical problems with the medication cabinet and hospital’s electronic health records system prompted Vanderbilt to instruct nurses to use overrides, so it was not unusual to have to use that functionality.)
- The withdrawn medication (vecuronium) was a powder form that needed to be reconstituted; Versed comes in a liquid form.
- In addition to the different drug name than what was ordered, “Warning: Paralyzing Agent” was written on the bottle.
- Vaught administered the medication and then left the patient in the waiting room for the test.
- Upon realizing the error, Vaught followed steps for reporting the incident.
- On January 3, 2018, Vaught was terminated for not following the five rights of medication administration and was reported to the Tennessee Board of Nursing.
There are more details in the timeline related to investigations and legal proceedings that can be found here.
What are the Issues?
We all know that medication errors happen; in fact, there are whole policies and procedures in place at most institutions to both minimize their occurrence and for reporting when they do occur. But we also know that when we are in a remote area of a hospital, there are less checks and balances, less monitoring, and more distractions.
The criminalization of nonintentional errors is concerning. Licensing boards and civil courts, not criminal courts, are the appropriate outlets to investigate and handle errors when they occur. The outcome of Vaught’s case sets a dangerous precedent. Will nurses, who are now working in the most trying of times during a nursing shortage and a pandemic, report errors and follow steps so that we can learn from them and improve systems to prevent errors?
When it comes to safety, we can liken our work as nurses to a goalie in a soccer game. When someone scores, the goalie is that last line of defense, however, the opposition got past all the other players before approaching the goal. As nurses, we are that goalie, but we are only one line – albeit the final line – of defense. Yes, we have a responsibility to prioritize safety, but without the proper support and safeguards in place, it can be really challenging to stop that ball every time. And when it gets by us, we must be prepared to discuss it and learn from it with our coworkers and leaders, safety experts, product and medication manufacturers, and administrators.