Every nurse’s nightmare.
On February 1, Radonda Leanne Vaught, a former nurse at Vanderbilt University Medical Center in Nashville, was indicted and arrested for impaired adult abuse and reckless homicide. She is accused of inadvertently administering the wrong medication and causing a patient’s death in an incident in late 2017.
This is every nurse’s nightmare.
According to the CMS report from its investigation, Vaught administered IV vecuronium (a neuromuscular blocking agent that causes paralysis and is often used during surgery) instead of IV Versed (a sedating agent) to an anxious patient undergoing a diagnostic scan. The patient stopped breathing, suffered brain damage, and subsequently died. Vaught was charged with recklessness because she overrode the automated medication dispensing system and didn’t follow standard procedures in properly checking the drug name or in monitoring the patient after administering the medication.
What the CMS report says.
The CMS report, which includes interviews with Vaught as well as witnesses and safety officers at the hospital, notes the following information about Vaught’s actions while she was in the medication system searching for the medication:
“[Vaught]. . . was talking to [an] Orientee while he/she was searching the ADC for the Versed and had typed in the first 2 letters of Versed which are VE and chose the 1st medication on the list. RN #1 [Vaught] stated he/she took the medication vial out of the ADC, and looked at the back of the vial at the directions for how much to reconstitute it with. RN #1 verified he/she did not re-check the name on the vial.”
The known dangers of distraction during medication administration.
Clearly Vaught didn’t follow proper and safe procedures and this led to a grievous error resulting in the patient’s death. Vaught was working with a new orientee and was explaining unrelated hospital procedures while in the midst of searching for the medication. We know from research that distraction during the medication administration process is a major cause of error. Hospitals have attempted to deal with the problem in multiple ways—for more on this topic, see “The Sterile Cockpit: An Effective Approach to Reducing Medication Errors?”
Charged despite lack of intent to cause harm.
This is not the first time nurses have been criminally charged after making unintentional errors. The case of Wisconsin maternity nurse Julie Thao was especially noteworthy because of her prior excellent record and the circumstances surrounding the situation; nurses, state and national nursing associations, and others publicized it and garnered support against her arrest.
Decrying a trend.
In 2012, the American Association of Nurse Attorneys (TAANA) and the American Association of Legal Nurse Consultants (AALNC) issued a position paper (pdf) against this trend of prosecuting nurse errors, stating:
“The criminal prosecution of health care providers for unintentional error endangers patients, demoralizes providers, accelerates their exodus from clinical practice, exacerbates the shortage of health care providers, contributes to a culture of blame, and perpetuates the unachievable expectation of perfection in practice. The criminal justice system should be invoked only in situations in which there is an actual intent to cause harm.”
It remains to be seen what will happen to Nurse Vaught. She’s due in court on February 20; no doubt many nurses will be following this story. A recent story in the Tennessean reports that in recent days, those who believe Vaught is being unfairly prosecuted have donated $43,000 for her defense.
UPDATE (March 1): Tennessee health officials have decided to take no disciplinary action against Vaught and found no wrongdoing.
When nurses have routinely scanned an armband & medication before administering the medication and then that safety process is not available, I can see how a non-thinking nurse might forget to perform the 5 (or 6) Rs. Also, hospitals sometimes change medication manufacturers and so one could possibily think the medication looks different (and now requires mixing) because it is from a different company.
In health care, there is very little room for sloppiness. Everyone, on occasion, becomes just a little bit complacent at work… whether from fatigue, not feeling well, unsafe work environment,etc… One can only hope that those occasions are rare and have little consequence. When it comes to anything related to medication, there can be no cutting corners.
A highly-respected RN friend with over 30 years experience told me that she used to pray before the start of her second (part-time) nursing job- she prayed that she wouldn’t make an error and kill someone during that shift. We laughed after her sharing that comment but she was dead serious. And I understood her completely.
Unfortunately, no human being is perfect and no system is perfect, but when it comes to providing health care for another individual, we can try mighty hard to get close.
I sympathise with all. There were a number of errors as pointed out but the one no one has mentioned is why is the system using trade names for drugs, that is fraught with danger. We also have an automated drug dispenser but all drugs are listed under the generic name and ordered by the doctor with the generic name, which in this case would be midazolam making it highly unlikely that this mistake would have been made at all. As I see it the first error here is a system error! Furthermore, we can only remove midazolam with the finger print of two nurses, not one. Another system error.
In addition, using generic names often gives a further warning by highlighting the drug family.
Our system certainly doesn’t eliminate all drug errors by any stretch of the imagination but it certainly does reduce them. This particular error would not have happened in our unit, the system would have prevented it – there wouldn’t have been any similarity between the two drug names, hence no need for someone to die and a nurse to be crucified.
The nurse fell far, far, below the standard of care here. Her multiple failures are so egregious criminal charges are inevitable. Vanderbilts actions and coverup deserve equal attention in a courtroom.
Why didn’t she scan the medication and the patient armband? How come she didn’t check the 6 patient rights? That medication wasn’t even ordered for the patient. She deviated from all of the safeguards that her hospital put in place to keep these mistakes from happening. Short of affixing an endotrachial tube to paralytics I don’t know how else to avoid this situation for her. And she should have known that you don’t reconstitute Versed. Also, the patient should have been on a monitor with Versed let alone Vec. It is HORRIFYING that she is a preceptor. She should not be criminally charged in my opinion. She should never be able to practice as a nurse ever again. She will live with this the rest of her life.
I too have been in a situation where I was working with an orientee and trying to administer medications that resulted in a medication error. In my case, my orientee drew up and administered 25mg of IV push Cardizem when the patient was only supposed to get 5mg. I had explained the process to my orientee prior to administering the medication, but while I had turned around to log into the computer and pull up the electronic MAR, my orientee had not only drawn up the medication but administered it as well. Our patient became symptomatic and we immediately notified the physician who happened to be on the unit at the time. Fortunately, this medication has a short half-life and our patient recuperated quickly. Unfortunately, it does not take much for a medication error to occur, as nurses we are very busy and often times are expected to perform tasks in a rapid manner. As for this nurse, and any other nurse in this situation, I don’t believe that charges this severe should be brought about. I do believe that there should be consequences, though. We have many safety procedures in place, and if they all would have been followed this should not have occurred. Yes, she was busy with an orientee, but why was the medication not rechecked prior to administration? Most facilities now have electronic mars that require scanning, and we have been taught that we should be checking medications and doses three times before administering meds. This was an accident, and a charge of homicide is ridiculous, but I do think some consequence is appropriate.
Did she go into work that day intending to harm someone?…probably not. Should her nursing license be revoked?…absolutely. But why add insult to injury? She must live with her error everyday. That is punishment enough I would think!
In my experience as an RN for 17 years, it appears that one failed systems error snowballs into a chain of reactions. In the case of nurse Vaught, the fact that she only typed two letters “ve” and was able to override a potentially deadly medication tells me that there should have been a better safeguard on the ADC. After that she was able to dilute the medication and administer it without the patient being monitored. Nurse Vaught was distracted and most likely in a hurry. There are many factors that contributed to this sentinel event. Nursing is a profession that lends itself to learning from errors and delving into process improvements. I am curious as to the events leading up to nurse Vaught’s arrest. Who was instrumental in contacting law enforcement? When other healthcare providers are implicated in sentinel events will they have criminal charges brought against them?
Just to make sure the facts are available here, the CMS report has all the details:
This was a neuro ICU patient who was about to be transferred out once the Pet scan would be completed
The nurse had no patient assignment that day. She was a “help-all nurse” who had worked in the neuro ICU for two years. She had her Critical Care certification. She had an orientee with her that day
She drew up the vecuronium in the neuro ICU where it was appropriately stocked for emergency use. She had search for versed in the patient’s profile and not seeing it, she tapped override and typed in ve. She then selected the first med from the list, which happened to be vecuronium.
it is unknown why she did not see versed in the patient’s profile. Pharmacy had verified the med 10 minutes earlier
She never looked at the vial her hand. It had the red cap with paralytic warning.
She reconstituted the vecuronium even though she should have known that versed is not a drug that needs reconstituting
She put it in a baggie with a handful of flushes and alcohol wipes and labeled it “versed”
She then went to the radiology department, told the patient she was giving her something to help her relax and then left.
The patient never went into the scan. She was in a room waiting for the radioactive tracer to circulate.
The patient was not monitored or observed for the next 25 minutes. She was found buy a transport person who noticed that she was not breathing.
Those are just a few of the facts found in the report from the nurses own testimony. I hope that it helps to understand the reason for criminal charges.
This story reminds me of the problem with concentrated potassium and deaths attributed to nurses drawing up the drug in error (usually during an emergency) and injecting it directly into a patient’s IV port. The 40 meq KCL vials looked exactly like the NSS flush vials. Many look-alike medications have helped cause similar horrific errors. The answer was to take all concentrated electrolytes off of the floors and pharmacy to mix and use factory premixed IV bags. Problem solved.
I cannot imagine confusing vecuronium with versed, but we don’t know all of the facts. Distraction is a legitimate problem. Since the patient was at a test and needed versed, we want to assume she was hurrying to get the med to keep the patient safe and to finish the test. Was the nurse competent to care for the patient’s acuity or was she floated from another unit? Should she have been orienting the other nurse in the first place? What kind of monitoring equipment was available and was it functioning?
Like the KCl, Vecuronium should not be on override outside of the ICU or OR, maybe not at all.
I once worked in a critical care unit where the nurses maintained a multi-drawer stock med supply for high acuity post op patients. The small drawers were labeled clearly. My patient went into SVT and I received an order to push 5mg of Lopressor prn. I opened the Lopressor drawer, took out the glass vial, broke the neck and drew up 4 cc of clear medication. I was shocked to not get the 5cc I expected and then saw that I had a vial of Levophed in my hand. I hoped that I would have rechecked the label and realized that someone had restocked the similar-looking Levophed vials in the Lopressor drawer. I want to believe I would have rechecked before injecting a lethal dose of the wrong drug into my patient. I was in a hurry to treat his rapid heartbeat. Perhaps the only thing that saved both of us is that I knew the drug I was trying to administer well and knew it should be 5cc, not 4.
I have no answer for this other than, like the aviation industry, we have to learn from every mistake and keep working to make making an error harder than doing the correct action. There but for the grace of God go all of us. I hope the family and this nurse can find some peace and mercy. A good long look should be had of every aspect of this tragedy before condemning this nurse.
We understand about distraction as factor in medication errors. However, part of professional responsibility is to recognize when what we’re being asked to do is unsafe. We also recognize that systems errors can have unexpected bad results. We’re all for doing what we can to eliminate the “culture of blame” in those cases. This was not the case here. Yes, vercuronium should never be available in a clinical area where there are no qualified people for immediate intubation. Yes, there should have been an alarm saying, “Danger, Will Robinson! Paralytic agent!” on the Pyxis screen. Yes, there should have been a place to document results of a prn med (and maybe there was). Yes, there was nobody to monitor the patient once she was put in the scanner. Yes, the patient’s family says she would have forgiven the nurse for her error (And what’s the source of this information? Did they ever ask about a situation where an error would cause her death?). And of course no sane nurse intentionally harms a patient, and of course she feels terrible about it.
But let’s focus on this: None of these matter because the nurse made an unforced critical error that every nursing student would recognize. She did not read the label on the medication before she put a syringe into it, drew it up, and injected it, and she did not observe the patient for the effect of the (supposed) sedative after she gave it.
No sane person who runs a red light intends to kill the person in the crosswalk, but the law provides for criminal prosecution if that happens nevertheless. I am not an attorney but this surely looks like negligent homicide to me: the killing of another person through gross negligence or without malice. But for that nurse’s violating the most basic medication administration principle, “right drug,” that woman would not have suffocated and would be alive today.
Absent systemic failure that made it inevitable or predictable, this horrible event and its aftermath cannot be inherently demoralizing or chasing people out of the profession. It’s reminding us all, once again, that we, ourselves, take responsibility for our patients’ safety at our hands on the day we begin licensed practice, and should be held accountable if we fail in that duty.