By Melissa Nguyen, Clinical Nurse Manager at Medical Solutions
I’ve been a nurse for 19 years and I remember my first medication error like it was yesterday. I was a new grad working in dialysis and I administered 5,000u heparin instead of 1,000u heparin. I recognized my error when my patient’s fistula wouldn’t stop bleeding when the needles were removed. I remember walking to the med counter and realizing the heparin label wasn’t the same color it usually was — the label looked exactly like the 1,000u heparin but the color of the label was a light blue instead of the usual light green.
I still remember that feeling in the pit of my stomach that I was responsible for my patient’s excessive bleeding. How did I not notice the bottles were different? I contacted the nephrologist, notified my administrator, filled out an incident report, and sat with my patient for more than an hour and a half until the bleeding stopped. Aside from having to stay longer than normal until her bleeding stopped, I was lucky my patient didn’t have any further complications.
Fast forward to February 1, 2019: That was the day that nurse RaDonda Vaught was indicted in Tennessee for reckless homicide in the death of her patient, Charlene Murphey due to a medication error at Vanderbilt University Medical Center. I couldn’t help but think of my own medication error and how drastically different Vaught’s error ended.
In December 2017, Vaught was taking care of Murphey who was hospitalized for a subdural hematoma. Versed had been ordered by a physician prior to a full body scan to help ease her anxiety from claustrophobia. According to court records, Vaught was unable to find IV Versed in the patients ordered profile, so she enabled the ‘override’ function in the medication dispensing system and typed ‘VE’ into the search field. This break in protocol led to a series of mistakes that ultimately led to the death of her patient.
According to prosecutors, Vaught ignored multiple warnings that the medication she was about to mistakenly remove was Vecuronium and not Versed. Vaught removed the Vecuronium, which unlike Versed, was a powder that had to be mixed before it could be given to a patient. She then mixed the medication and admitted to being “distracted” which caused her to miss the bright orange warning on the bottle stating “WARNING — PARALYZING AGENT.” Vaught then administered a lethal dose of Vecuronium, which ultimately paralyzed Murphey’s respirations leading to her untimely death.
Co-workers described RaDonda Vaught as a respected, well-liked, competent nurse with a spotless track record. She admitted that she made a mistake by using the override feature and by not recognizing the warnings on the vial. Vaught’s supporters believe that criminalizing mistakes will lead to underreporting of errors and the inability to identify other factors that led to mistakes being made.
So, what can you learn from this case and how can you protect yourself?
Know the five basic rights of medication administration and use them every single time.
Right 1: Right patient
Right 2: Right medication
Right 3: Right dose
Right 4: Right time
Right 5: Right route
Monitor your patients to watch for adverse effects.
In Vaught’s case, she did not record the administration of medication and left the room immediately without monitoring the patient. Murphey was found unresponsive and pulseless 30 minutes after the Vecuronium was given. Had Murphey been monitored, she would have shown signs of respiratory failure within minutes of receiving the medication. Be mindful of the medications you administer and the possible side effects that could occur.
Follow policy and procedures.
While overrides may need to be used under emergent situations, they are not to be used under routine circumstances. Safeguards are put in place for a reason. Should you find yourself in a similar situation where a medication is not showing up on a patient profile, do not override safeguards without contacting pharmacy, a charge nurse, or another fellow nurse to help troubleshoot.
The blame should not be entirely placed on Vaught, as there were also failures identified within the hospital system. In the end, this is truly a tragic incident that led to the death of a patient and a nurse with pending criminal charges. No matter how you look at the situation, it is devastating for everyone involved. None of us are immune from making mistakes, however, it is our responsibility stay vigilant in adhering to basic fundamentals set in place that ensure patient safety!