The RaDonda Vaught case, in which a nurse mistakenly administered the wrong medication, resulting in a patient’s death, drew significant attention from nurses and other healthcare practitioners.
The primary reason was Vaught’s trial and conviction for negligent homicide, which raised serious questions among nursing professionals. However, the case also brought attention to the importance of consistently following medication safety protocols without exception. This includes adhering to the rights of medication administration — the right person, medication, dose, time, route, reason, and documentation—to help prevent errors.
In the following case, a certified registered nurse anesthetist (CRNA) didn’t fully adhere to those rights, and as a result, the patient was injured and the state board of nursing took disciplinary action.
Details of the case
A CRNA, alongside a supervising anesthesiologist, assisted with a total knee replacement by performing a spinal block on the patient. An automated dispensing system correctly dispensed two medications — the spinal block (aka local anesthetic) and a medication to reduce bleeding.
The spinal block required a sterile field, so the CRNA gave the spinal block and a spinal tray to an anesthesia technician, who placed the vial of the spinal block aside so he could hold the patient during the procedure.
The CRNA asked for the spinal block. Still holding the patient, the technician reached for a vial and asked the CRNA, “Is this the one you want?”
The CRNA replied, “Yes,” but didn’t look at the label on the vial nor ask the technician to read the name on the label out loud. The medication was administered to the patient. Afterward, the CRNA found that the spinal block vial was underneath the wrapper of the spinal tray while the open vial of the other medication for reducing bleeding was on top of the anesthesia vent.
The CRNA immediately informed her supervising anesthesiologist and the knee replacement surgery was canceled.
The patient initially appeared stable but later developed seizures, requiring transfer to the ICU and intubation. He was then transferred to another hospital and experienced two additional hospitalizations. Eventually, he was diagnosed with an anoxic brain injury.
State board files complaint against CRNA
The state board of nursing’s complaint against the CRNA alleged that she engaged in unprofessional conduct and failed to meet the minimum standards of nursing practice.
The CRNA denied the allegations, and a hearing was set before an administrative law judge. Both the board and the CRNA presented testimony. The judge issued a “proposal for decision,” holding that the board had met its burden of proof to establish that the CRNA was subject to discipline and recommended that the board suspend her license for two years.
At a public hearing, the board issued a final order adopting the judge’s findings and conclusions and imposed a two-year suspension.
The CRNA sought a judicial review of the case in court. The district court affirmed the board’s order, and the CRNA appealed that decision.
An appellate court reviewed the state law applicable to her specific legal situation based on the CRNA’s challenges to the board’s decision. The challenges included:
- The board’s findings and conclusions were not reasonably supported by substantial evidence.
- The medication injected was unaccounted for at the time of the injection.
- The board’s suspension was arbitrary and capricious.
The appellate court upheld the district court’s ruling, affirming the board’s order of a two-year suspension. In doing so, it ruled that:
- There was substantial evidence to support the board’s findings and conclusions.
- The CRNA’s testimony during the board hearing that she did not remember the exact location where she placed the vial of the medication to reduce blood loss and bleeding was the most credible of all her testimony surrounding the location of that vial.
- The CRNA didn't meet the minimum standards of nursing practice for medication administration. This included not adhering to the rights of medication administration, not verifying the medication label herself or asking the anesthesia technician to read it before drawing the medication, and neglecting her responsibility as a licensed CRNA to ensure proper accountability for all medications used in the procedure.
The CRNA claimed the suspension was arbitrary and capricious, arguing it didn't comply with the board's rules for appropriate discipline. However, the court ruled against this allegation because she failed to raise the issue during the board hearing or the judicial review process.
What you can learn from this case
The appellate court's decision highlighted the need to follow the rights of medication administration. In this case, while the CRNA obtained the correct medication vials from the automated dispensing system, her administration of the medication failed to meet the required standards of care.
This case also reinforced that the CRNA held sole responsibility for verifying the accuracy of a medication before administering it.
Testimony from other CRNAs played a key role during the hearings. The board’s CRNAs provided more compelling testimony, meeting the burden of proof regarding the CRNA defendant’s legal, professional, and ethical obligations.
