The original intention of this blog is to help foreign-educated nurses navigate through the nursing practice once they migrate abroad. With that said, I honestly feel that this story of a nurse convicted due to a medication error warrants a discussion since not everyone understands the legal process here in the United States. Needless to say, this impacts the practice of current and future nurses in all settings as well as the totality of healthcare. I will cite as many sources as I can as far as workflow, patient safety, and relevant perspectives are concerned. As with all news stories, let us start by learning the facts of the matter.

RaDonda Vaught was a former nurse who worked at Vanderbilt University Medical Center in Nashville, Tennessee. She was arrested in 2019 for reckless homicide and gross neglect of an impaired adult. Her patient, Charlene Murphey, 75, died after Vaught administered Vecuronium ( a paralytic medication) instead of the intended Versed (a sedative drug).

Murphey was admitted to the hospital in December 2017 due to subdural hematoma and her condition was improving. A positron emission tomography (PET) scan was scheduled prior to her discharge. The provider ordered Versed (generic name: Midazolam) to help calm her down during the procedure.

An intensive care unit (ICU) nurse, Vaught was working as a “help all” or resource nurse during that unfortunate day. Requested to help with Murphey’s care, she proceeded to the imaging department with her orientee.

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Facts and Timeline of Events

The Nurse’s Fault vs. Systematic Failure

Using the automated dispensing machine (ADC), she checked the patient’s profile but was unable to see the Versed order. After checking the patient’s electronic health record (EHR) and confirming that there was an order, she utilized the override function of the ADC and typed in VE (first two letters of Versed).

Without realizing that the medication dispensed was Vecuronium instead of Versed, Vaught alleged that she did not see any warnings popup. She confirmed that she saw the powder inside the vial that she took out. Vecuronium comes in powder form, while Versed is in liquid form.

One of the prosecutors mentioned that the nurse did not read the label but just went on and reconstituted the said drug. Upon arrival at the imaging department, she administered the medication to the patient without using the bar code scanner. The defendant also failed to assess and monitor the patient. Instead, both she and her orientee left. The PET scan tech oversaw the patient while the contrast was circulated in the bloodstream. The transporter who came to pick up the patient discovered that the patient was no longer moving nor breathing.

They called rapid response, performed resuscitative efforts, revived the patient, and transferred her back to the ICU. Early morning the next day, the patient succumbed. Here is the rest of the timeline as far as this case is concerned. Furthermore, here are the details of this unfortunate incident.

Realizing that she made a mistake, Vaught followed prescribed protocols and self-reported her medication error. She escalated this matter to her leader and other appropriate stakeholders. Vanderbilt fired her eight days later.

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Expected Workflow

Specifically focusing on medication administration, this process usually starts with the provider entering a computerized provider order entry (CPOE). The pharmacist then reviews the order. That confirmation from the pharmacy allows that ordered medication to populate in the patient’s profile in the ADC. Depending on organizations, nurses are able to override medications from the ADC.

From my own experience, high-risk medications such as Versed and Vecuronium are not among those that we can freely pull out on an override functionality. Also, high-risk medications are accompanied by alerts that display on the screen of the ADC. It will prompt the nurse to perform an initial count for inventory purposes.

At the bedside and if technology is available, bar code scanning is a must. Yes, nurses can bypass using them. That is a workaround. However, administering high-risk medications like these calls for independent verification or a dual signature from a fellow nurse. Both of them have to review the five rights of medication administration. They are ensuring that the right dose of the right medication is administered to the right patient via the right route at the right time.

You may have heard of the line:

The buck stops with me!

This is very sacred in nursing in the sense that we are the last line of defense. In a nutshell, we are that thin layer that prevents an error or a series of errors from adversely affecting our patients.

Swiss cheese model by James Reason published in 2000. This is the black and white version (2001)

Swiss Cheese Effect

The Swiss Cheese Model proposed by James Reason has been the go-to paradigm in the analysis of medication errors and patient safety events (Perneger, 2005). It illustrates a series of barriers that prevent an error from reaching the patient. However, if the holes are aligned despite the presence of barriers, the error can potentially affect the patient in an adverse manner.

The nurse performed workarounds and bypassed some safety protocols. That is a fact. However, stakeholders needed to conduct a thorough investigation if some system processes also contributed to the mistakes.

For example, why was the nurse able to pull out a high-risk medication from the dispensing machine even if the pharmacist has not yet verified the order? What is the acceptable alternative workflow in medication administration if a bar code scanner is not available?

Was firing the nurse the best course of action? Or will it just lead to an increase of unreported mistakes resulting in more patient safety issues? Is there a patient safety committee that is overseeing these mistakes and identifying opportunities for learning? Will high-reliability tools such as STAR (stop – think – act – review) prevent occurrences like this from happening again?

Healthcare organizations (HCOs) strive to provide safe and quality care to patients and clients. Stakeholders continue to identify and mitigate errors from resulting in adverse consequences. Gathering safety event reports is one way of doing this. However, if clinicians feel that their errors can and will be held against them, will they be forthcoming in reporting them still?

Just Culture

 Just Culture is a model that explores the role of punitive sanctions when people, particularly clinicians, make mistakes. It defines the three classes of mistakes: simple human error, at-risk behavior, and reckless behavior. Just Culture follows the nursing process. If adopted by an organization, it fosters, teamwork, collaboration, openness, and transparency.

Non-deliberate errors present learning opportunities. Nurses utilize peer coaching and education to cement fail-safe mechanisms that will prevent a similar error from happening. In contrast, blame and immediate punishment negatively impact the morale and the quality of care provided by the team members.

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My Two Cents

 As a Bedside Nurse

Back in the day, I was one of the patient safety coaches in our Pediatric unit. We lived by the Just Culture and the high-reliability tools daily. Our leaders encouraged patient safety event reports. Those reports averted potential errors from reaching the patients. We called them “near misses.”

Sure, there was that tinge of guilt whenever one makes a mistake. However, we looked at it from a constructive perspective. For example, by utilizing bar scanning, I was able to prevent feeding the wrong breast milk to the wrong baby. My manager discussed the situation with me and together we explored opportunities for process and workflow improvement.

As a Clinical Informaticist

Working with the EHR and the tech tools on the front lines, it is important that we monitor the clinicians’ consistent and appropriate use. We pull up and review reports regarding non-compliance and refer them to the appropriate leaders for team members’ coaching. We also emphasize during our end-user classes the importance of following the recommended workflow. Workarounds (e.g. bypassing dual sign-off for high-risk meds) may result in adverse incidents, so we discourage them.

Implications to Nursing Practice and Healthcare

The American Nurses Association issued a statement regarding this verdict. In part, it reads:

“We are deeply distressed by this verdict and the harmful ramifications of criminalizing the honest reporting of mistakes.”

Prior to the verdict, the Institute for Safe Medication Practices (ISMP) has issued its own statement relative to the revocation of Vaught’s nursing license. The institute asserted that:

Clinicians will avoid speaking up if there is a likelihood that their unintentional mistake will be used against them. This will hamper learning from non-fatal mistakes and prevent improvements in system design. Afterall, who will want to volunteer information that may lead to losing one’s license or even jail time?

ISMP predicts that this will jeopardize the chance to recruit promising clinicians. This makes it harder for all stakeholders already struggling in the midst of an obvious nursing shortage and a post-pandemic healthcare industry currently on life-support.

What about you? What are your sentiments regarding this rare but consequential patient safety case?