Last week I wrote about medication mistakes in hospitals and the factors that make them so common and so deadly.  This week I want to write about the Tennessee nurse whose medication error killed a patient and who ended up being prosecuted and convicted in the death.

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RaDonda Vaught was only two years into her nursing career in 2017 when she made a mistake that will haunt her for the rest of her life.  She was assigned to administer a sedative, Versed, to an elderly patient who was about to undergo an MRI scan and who was anxious about the procedure.  Instead of Versed, she mistakenly administered a powerful paralyzing agent, Vecuronium, and left the patient to be taken to the MRI scan by an orderly.  When the orderly arrived at the patient,  he found she had stopped breathing due to the medication and was in cardiac arrest.  She was brain dead and died a few hours later.  Nurse Vaught was charged by local authorities with reckless homicide and with gross neglect of an impaired adult.  She was acquitted on the homicide charge but convicted on the charge of gross neglect.  She was sentenced to three years probation and lost her nursing license.

As is almost always the case, there were a number of contributing factors and Nurse Vaught may have been one of the least culpable participants in this tragedy.  The death and resulting investigation revealed many systemic problems that threaten patient safety today and yet persist in hospitals across this country.

The death in question occurred at Vanderbilt University Medical Center, one of the most prestigious hospitals in the United States.  That pretty well assured that, if prosecutors were going to go after anyone for this death, it was not going to be Vanderbilt University Medical Center, even though an agent of the Tennessee Bureau of Investigation testified its investigation found Vanderbilt to be greatly responsible for the death.  Unfortunately, Vanderbilt’s status as a sacred cow increased the odds for Nurse Vaught that she was going to be the one left holding the bag.  There were many issues at the hospital that set the stage for this error.

Nurse Vaught had to get the medication from an automated drug dispensing machine. To obtain a drug from the machine, she had to enter the first two letters of the name of the drug.  The machine would then produce a drop down list of drugs beginning with those two letters.  Because there are so many drugs with similar names and because there had been problems with nurses selecting the wrong drug, the manufacturer had sent out a software patch that, when installed, would require the nurse to enter the first three letters of the drug name.  At least in part because this slowed down the process, some hospitals had not installed the software patch.  Vanderbilt was one of those hospitals that had not installed the patch.  Requiring three letters would have greatly reduced the number of drugs on the drop down list and would have prevented this particular mistake.

The hospital was switching over to a new electronic medical record keeping system.  The rollout was not yet complete and there were many problems.    The drug dispensing machine was supposed to communicate with the electronic medical record to confirm that the medication selected by the nurse was one ordered for the patient.  The machine was not able to communicate with the electronic medical record because the switchover was not yet complete.  It therefore did not list any medication for the patient beginning with the letter VE.  This type of problem was widespread and the hospital had instructed the nurses to use the machine’s override feature when it was not responding properly.  Nurse Vaught used the override feature to get the machine to offer a larger list of medications beginning with VE from which she selected Vecuronium.  Nurse Vaught thought little of having to override the machine since it was done so frequently.  She admits she should have checked to make sure her assumptions were accurate at this point before proceeding.

At the time she was drawing the medication, Nurse Vaught was introducing a new hire to the hospital and its procedures.  She was explaining things to him and this was a distraction that certainly played some role in her mistake.

Nurse Vaught was required to administer the medication within a certain time frame or the patient would have to be sent back to her room and rescheduled for the scan.  Her haste to meet the time deadline played a role in her error.

The paralytic agent dispensed by the machine was a powder, which was different from the way Nurse Vaught had seen Versed in the past.  However, because recent hurricanes had disrupted supply chains, the hospital was getting many drugs that looked different from the way they usually appeared.  Many of them had to be reconstituted from powder where before they had not.  This was another point at which Nurse Vaught could have stopped and reassessed her actions, but did not.

Confirmation bias is a strong factor in many human actions and was important here as well.  Nurse Vaught expected that she would be given the correct medication by the machine and saw what she expected to see.  Confirmation bias remains a problem in hospitals today.

Nurse Vaught came forward and reported her error.  Although that is what hospitals and the medical profession says it wants, it did not work out well for Nurse Vaught.  She was fired, criminally prosecuted and lost her nursing license.  Her experience is unlikely to encourage others to be similarly open about their mistakes.

There was nothing this poor patient could have done to prevent her death.  This type of error continues to not only be possible but inevitable.  As we build more and more complicated systems, we tend to rely more and more on their infallibility with tragic consequences.

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