Beyond the RaDonda Vaught Case: Avoiding Medication Administration Errors

By | 2022-04-12T15:52:20-04:00 April 11th, 2022|4 Comments

By now you have heard, read, and experienced various emotions about the jury conviction of former nurse RaDonda Vaught of criminally negligent homicide and impaired adult abuse after mistakenly administering the wrong medication to a patient in the PET scan unit, which resulted in the patient’s death.

The nurse also lost her RN license prior to the conviction.

Many articles and other news coverage methods have focused on the RaDonda Vaught trial. In addition, the American Nurses Association (ANA) and the Tennessee Nurses Association (the state affiliate of the ANA and the state within which she practiced) issued a response to the conviction.

I thought it best not to focus this blog on comments and media coverage about the trial. Besides, I’m sure you have your own thoughts about the reported facts of the case and what ensued afterward.

Rather, I would like to highlight how you can hopefully avoid being in her shoes through a review of some medication administration principles that minimize the errors that reportedly occurred during her mistaken administration of the wrong medication.

Some Principles for Medication Administration

The following list is based on standards of practice and standards of care for medication administration. Each is important in and of itself and should be utilized every time medication is poured and administered.

At any one time, one of the items may be more important than the others, but all need to be given undivided attention when undertaking the extremely important, but risky, task of medication administration.

  • Always adhere to the “rights” of medication administration: right patient, right medication, right dose, right time, right route, right assessment of the patient before administering, right evaluation of the patient after the medication is administered, and right documentation.

Obviously, the nurse did not meet the right medication requirement which proved to be a fatal failure.  Additionally, she did not evaluate the patient after the administration of the wrong medication.  Rather, she left the patient after the drug was administered.

  • Access and administer medications without distractions.

According to one article, the CMS investigation revealed that the nurse was talking to a new nurse she was precepting about a Swallow Study they were going to do next at the time she typed the medication into the automated dispensing system.

  • Always check the label on the medication against the medication order, visually inspect the medication vial or other container, and ensure that the medication has not expired.

According to the Tennessee Bureau of Investigation report, the nurse did check the Versed order with the patient’s MAR, but only looked at the back of the vecuronium bromide container, and thought it “a little odd” that she had to reconstitute the medication.

  • Utilize mindfulness during the medication administration process by being aware and taking a thoughtful approach to clinical decision-making and error interruption.

The nurse’s job title was a “help all” nurse, meaning that she helped provide nursing care for “urgent or emergent” needs when nursing staff could not do so. She was asked to go to the PET scan unit to administer the anti-anxiety medication because a patient was anxious about an ordered scan. She was to do a Swallow study next. In addition, as stated above, she was precepting a new nurse.

  • Know the purpose, actions, “usual” dosage, contradictions, and side effects of medications you prepare and administer.

Versed is a liquid while vercuronium bromide, which she administered, is a powder that needed to be mixed into liquid.

The automated dispensing system had Versed programed under its generic name, midazolam, of which the nurse was   unaware. When she searched for “VE” in the system, it could not be found due to the generic name listing and not the brand name.

  • Rarely use any override option available in an automated dispensing system, especially for “high alert” drugs. If a medication is not found, or warning messages appear, seek input from the pharmacy or a nurse colleague.

According to a Tennessee Bureau of Investigation report the nurse used an override option to search for more medications, using the “VE” designation again. Moreover, she overrode five warnings that the medicine she was withdrawing was a paralyzing agent. Five additional “red flags” were also ignored. The cap on the vecuronium bottle had another warning: “Warning: Paralyzing Agent.”

  • If you do administer a medication in error, no matter what the error is, report it immediately.

The nurse did report her error to the acute care nurse practitioner and a physician after the patient had coded in the PET scan unit and was brought back to neuro ICU.

 The medicine administration guidelines presented here are but a few of the further points you should review, rereview, and rereview. You have a legal and ethical obligation to adhere to standards of practice and standards of care applicable to your role in the process of medicine administration.

It is important to note, however, that your role in this process is shared with the facility in which you work. Your facility has legal and ethical obligations as well to develop and enforce safety measures and guidelines for the safe and proper administration of medications.

In fact, many believe that medication errors are not the result of just the nurse or another healthcare provider involved. Rather, such errors are more systemic in nature, and the facility system has a responsibility to ensure safe practices of medication administration.

There is no doubt that you are accountable and responsible for your nursing practice. If your nursing care results in an injury or death to a patient, these principles can result in a loss of license, a civil lawsuit for professional negligence, a criminal conviction, or all three.

However, blame in and of itself does no one any good. Instead, systems of health care and nurses need to support each other and make the role of providing medications for treatment a safe one for all concerned.

The facility and its nursing staff (in one way through the reporting of medication errors so they can be evaluated) must analyze the error, adjust policies and procedures as needed, and require safer approaches to medication administration. This process depends on accurate and immediate reporting of a medication error.

Patients’ lives depend on achieving this goal.

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About the Author:

Nancy J. Brent, MS, JD, RN
Our legal information columnist Nancy J. Brent, MS, JD, RN, received her Juris Doctor from Loyola University Chicago School of Law and concentrates her solo law practice in health law and legal representation, consultation and education for healthcare professionals, school of nursing faculty and healthcare delivery facilities. Brent has conducted many seminars on legal issues in nursing and healthcare delivery across the country and has published extensively in the area of law and nursing practice. She brings more than 30 years of experience to her role of legal information columnist. Her posts are designed for educational purposes only and are not to be taken as specific legal or other advice. Individuals who need advice on a specific incident or work situation should contact a nurse attorney or attorney in their state. Visit The American Association of Nurse Attorneys website to search its attorney referral database by state.

4 Comments

  1. Avatar
    Tina April 17, 2022 at 11:38 am - Reply

    I find this article disturbing.
    I am a nurse and I understand the 5 rights. Unfortunately we don’t work in a vacuum. Family patients, PT, OT and various phone calls WILL distract you. They all need your attention.

  2. Avatar
    Shirley April 17, 2022 at 9:39 pm - Reply

    Seriously? When was the last time you worked the floor? Short staff, more demands, constant interruptions. In the case of Vanderbilt hospital, their whole system failure and blatant disregard for safety, by telling the nurses to override meds without weighing the consequences., Vec should never be an overrideable medication. Yet, they walk away pretty much untouched. Having an oriented, a float nurse with only 2 yrs of experience being pulled all over the hospital. Maybe having safe ratios, and better schooling, and hospital accountability for unsafe practices. Yes, the nurse should have caught it, however, an mistake was made and for some reason she is the scale goat. Maybe its time for upper management to get off their high horse and see what’s going on on the floor, and see that things are unsafe for both the staff and patients. Bottom line is safety. Not money!!

  3. Avatar
    Evelyn Cordero April 19, 2022 at 12:41 pm - Reply

    The most significant systemic problem I identified is the fact that the doctor’s ordering system allowed for entering the medication order differently to how it is listed by pharmacy. That is a big discrepancy that led to the error when the nurse is trying to find the medication. Also a position as such should have a nurse that is experience with.

    Medications such as Versed, which is by anesthesia as a sedative not anti-anxiety. The doctor ordered a med that was not appropriate for this patient, however it was the nurse the only one facing the charges.

  4. Avatar
    Tanya McIntosh April 21, 2022 at 8:54 am - Reply

    Facilities claim to practice the root cause philosophy for incident investigations. Practice continues to focus on blaming the nurse. I have many issues about this case including the nurse’s assignment and exempting pharmacy from any scrutiny.

    When I teach med errors I tell the students to always consult a resource and to be able to show that resource for support of your actions. This step would have reminded her of the generic name. She expected the pyxis to id both names.

    In my area 12 residents died in a nursing home and the owner and administrators were not charged. They charged an LPN and a CNA. No decision makers were included.

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