Case of Nurse Charged with Homicide for Medication Error Raises Concerns

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 […]

2019-03-01T14:14:51-05:00February 12th, 2019|Nursing, nursing career|10 Comments
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Patient Safety: The Basis for Nursing

Making patients safe is where nursing begins.

by Lars Plougmann/via Flickr

It doesn’t matter how or where a nurse may practice—acute care, long-term care, home health, school nursing—making sure patients are safe is where nursing begins.

In 1999, the famed Institute of Medicine (now the National Academies of Science, Engineering and Medicine) report, To Err is Human: Building a Safer Health System, woke us up to the fact that medical errors were causing thousands of deaths annually in the very places where people go to restore their health. In 2004, another report, Keeping Patients Safe: Transforming the Work Environment of Nurses, detailed nursing’s critical role in health care delivery, particularly in ensuring patient safety.

We can always do better.

While there have been significant improvements in reducing adverse events, and nurses are leading many quality improvement initiatives, we can always do better. In May 2016, I wrote the following in an editorial (“A Culture of Safety Stars With Us“):

“Nurses have always been the sentinels, the around-the-clock watchers, detecting the changes that might herald a patient’s deterioration. Nurses are the ones that the system looks to—and often blames—when there’s a failure to rescue.”

This is still true.

This week marks an emphasis on patient safety—it’s what we do every day. In honor of the week, we’ve made the […]

2018-03-13T07:59:37-04:00March 13th, 2018|Nursing|0 Comments
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Getting It Right: Putting the ‘QI’ in Quality Improvement Reports

Towards a Safer Health System

Photo of AJN editor-in-chief Shawn KennedyEver since the famous report To Err is Human: Building a Safer Health System was issued by the Institute of Medicine (now the National Academies of Sciences, Engineering, and Medicine) in 1999, health care institutions have been pushed towards reducing errors and increasing safety.

Changes have been spurred by accrediting and government organizations like the Joint Commission and the Centers for Medicare and Medicaid Services, by independent and professional initiatives like the Institute for Healthcare Improvement and the Magnet Recognition Program, and by consumer advocacy groups like the The Leapfrog Group and the National Patient Safety Foundation.

Nursing Education and Quality Improvement

Nursing, as the largest department in hospitals and the one tasked with shepherding patients through the system, is a key player in any system redesign and many nursing departments are playing an active role in improving the safety and quality of care.

Nursing education has also embraced the QI movement, adopting the Quality and Safety in Nursing (QSEN) program in many curriculums and also making it a hallmark of its doctor of nursing practice (DNP) programs. Developing and implementing QI projects is frequently a requirement for completing these programs. […]

2016-11-21T13:00:57-05:00September 29th, 2016|Nursing, nursing perspective, nursing research, patient safety|0 Comments
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To Err is Human . . . To Improve Elusive?

Peggy McDaniel, BSN, RN, is an infusion practice manager and occasional blogger

As a nurse working in the quality improvement and patient safety arena, I’m not surprised that the title of a recent article at Fierce Healthcare got my attention: “Hospitals Are Bad for Your Health.” The article highlights a recently released report from the Department of Health and Human Services Office of Inspector General based on a study of Medicare patients discharged in 2008. Among other things, it revealed that “44% of adverse or temporary harm events were clearly or likely preventable.” The usual culprits were to blame:

  • infections
  • medication errors
  • surgery-related errors
  • patient care issues

Most of these have been previously labeled as “never events” by the Centers for Medicaid and Medicare Services (CMS), and currently hospitals are not being reimbursed for the costs incurred if one or more of these happen to a patient while in the hospital. CMS was the first to implement such a pay-for-performance model—and major insurance companies have followed their lead.

In recently published NEJM study, 63% of the adverse events reported in the hospitals studied were deemed preventable. This study was disheartening because we recently passed the 10-year anniversary of the release of the

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2016-11-21T13:14:47-05:00December 1st, 2010|nursing perspective|3 Comments
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Views expressed on the blog are solely those of the authors or persons quoted. They do not necessarily reflect AJN’s views or those of Wolters Kluwer Health/Lippincott Williams and Wilkins.
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