If you are currently working in healthcare, particularly in the United States, and have not heard of the RaDonda Vaught trial, you must have been hiding under the rock. Vaught is a former nurse who was convicted last month in Tennessee. Committing an unintentional medication error that caused a patient’s death led to that conviction. While she reported her mistake to her leader immediately, the bigger question is: is she solely to be blamed for that? Or were there systemic factors that led to the unfortunate event?

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Short Synopsis of the Incident

Vaught was a Neurological Intensive Care Unit (ICU) nurse. That fateful day in December 2017, she worked as a “help all” nurse. In a nutshell, she helped as needed.

Her ICU colleague instructed her to administer a sedative to an anxious patient awaiting for positron emission tomography (PET) scan procedure. Instead of removing Versed, the ordered medication from the automated dispensing cabinet (ADC), she got Vecuronium. She utilized the override functionality of the ADC after not seeing the verified Versed order on the patient’s profile.

Long story short, she administered the wrong medication. She also did not assess and monitor the patient after confirming with the provider that there was no need for monitoring. After 30 minutes, a transporter found the patient not breathing and not moving. They called a code and resuscitated the patient, but she succumbed the very next day.

Realizing the mistake, Vaught self-reported to her manager. She verified if she needed to document the said medication in the patient’s chart. Her manager informed her that there was no need for her to do it. After speaking with her leaders and the risk management team, her hospital fired her eight days after the incident.

Read more here and here about in-depth details regarding this timeline of events.

Analyzing the Mistakes Committed

Ethical principles guide nursing practice. Nurses are aware of the four ethical principles: autonomy, beneficence, nonmaleficence, and justice. Particularly attributed to nonmaleficence are:

To do no harm or to protect patient safety.

Based on this, let us consider that Vaught did not intend to harm, much more to kill, Ms. Murphey. She was just there in her capacity as a “help all” nurse to administer the ordered medication.

Medication Administration Workflow

There is a common workflow for medication administration. I mentioned our own workflow in my practice in one of my past blog posts. Let us apply those steps here now to identify which were adhered to and which ones were not, focusing on the human factors first:

Before Administration of Medication

1. The provider enters the order via computerized provider order entry (CPOE). (The provider utilized CPOE).
2. The pharmacist verifies the entered order. ( This was done.)
3. The nurse checks the patient profile in the ADC to ensure that the ordered medication appears. (She did this but was unable to find the medication under the patient’s profile). *
4. The nurse checks the patient’s electronic health record (EHR) system to confirm the order. (She performed this).
5. The nurse goes back to the ADC to remove the ordered medication. Depending on the organization, override functionality is available for use. (She used the override functionality).*
6. The nurse reviews how a medication is to be given by checking on the label in the vial. (She partially did this because she was able to see that the medication was in powder form, and thus needed reconstitution.)*

During and After Administration of Medication

1. The nurse has to use the bar code scanning technology, if available. Otherwise, she has to verify the patient’s demographics (name, date of birth, etc.) as well as the medication she is giving. (She verified the patient’s information. However, she failed to double-check the original packaging of the medication before giving it.)*
2. For high-risk medications (e.g. sedatives, paralytics, etc.), dual verification is a requirement. (She did not verify the medication with her orientee).
3. The nurse manually documents the medication administered in the absence of bar code scanning technology. (She did not do this.)
4. Some organizations require that nurses monitor patients for a specific period of time if they receive sedatives or other high-risk medications. (She did not do this either).*

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The Human Factors

Based on the workflow listed above, there was a mix of what was done and not done. The recognition that she made mistakes by not paying close attention prompted her to self-report to her leader. That reporting, more than just owning to her mistakes, was also her way of seeking guidance on the next best step to take.

She offered to document the medication administered. However, her manager told her not to. Why was there no need for documentation if the purpose was transparency? Is it part of the hospital’s policy to conduct an independent verification when giving high-risk medications?

Did the fact that she was a “help all” nurse contributed to the mistakes she made? Did she have a manageable workload at the time she made the mistake? Was having an orientee distracted her in any way? After she reported her mistake, was there a debriefing session to analyze what went wrong? Were there learnings on how to prevent them from happening again?

Other questions may be: Was she working a 12-hour shift that day? How many days was she working that week? Was she working consecutive days? What is going on in her personal life?

The Systemic Factors

The items indicated by asterisks (*) were potential systemic factors. Let’s go through them one by one:

The ADC Angle

• The patient’s profile did not include the ordered medication. She used the override functionality after verifying that there was a CPOE (Items 3 and 5).

The override functionality is an option for nurses to remove medications without a provider’s order or a pharmacist’s verification. This is especially true if the patient needs that medication right away. Most organizations limit the kinds of medications nurses are able to override, however. This does not include high-risk medications which potentially can cause adverse reactions to patients. With that being said, why was she able to override Vecuronium, a paralytic medication? Was the fact that the organization just recently transitioned to a new EHR system a factor in the delay of Versed showing up in the patient’s profile?

• High-risk medications come with labels and ADC screen warnings when removed (Items 3,5, and 6).

Even though she used the override functionality, a warning should still have popped up on the screen. At the very least, there should have been a prompt for her to count the medications in stock. Did the warning pop up? Was there the correct label and warning on the vial? Did the vial have almost similar labels to other medications?

Bar Code Medication Administration (BCMA)

• Using the BCMA prior to giving the medication (Items 7, 8, and 9).

BCMA is considered one way of ensuring the five rights of medication administration. A nurse essentially utilizes a bar code scanner to scan the patient’s bracelet. That positively identifies the patient. Then he/she has to scan the medication to reconcile that with the order. In the absence of a bar code scanner, a nurse is still able to document that given medication through manual charting. Was manual charting an acceptable workaround in this instance? Why did the leader dissuade Vaught from doing so?

Whether using the BCMA or manual charting, high-risk medications warrant independent dual verification of two nurses. The Institute of Safe Medication Practices highlights its importance as one of the strategies that prevent mistakes from reaching the patients. However, nurses either underutilize or misuse it.

Institutional Policies

• The nurse did not monitor the patient after giving the high-risk medication (Item 10).

The report regarding this reiterated that Vaught should have monitored the patient. High-risk medications have a higher potential to cause adverse reactions in patients, thus the need for close monitoring. The question in this particular situation is: did the fact that she followed the provider’s instruction that she did not need to monitor the patient absolve her from that responsibility?

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Conclusion

As we can see, there are so many factors that come into play when mistakes happen. In the light of Just Culture, situations like this warrant a root cause analysis. The Risk Management, Ethics, Institutional Leadership, and the person/s concerned usually convene to find out the details of what happened. They look into preventable factors that may be mitigated to avoid a similar situation from happening again.

Unfortunately for Vaught, her workplace held her mistakes against her and fired eight days after the incident. The prosecutors also did a great job in convincing the jurors to only look at the processes she did not follow and not the systemic factors. As a result, she doesn’t have a license and may even go to prison.

Nurses can only imagine what these or the sentencing in May bring to the profession!

I think this warrants a discussion amongst past, current, and future nurses. Start by commenting below.