Preventing Medication Errors: the case of RaDonda Vaught

Updated 10/15/2021 – K. Kreis, MSN, RN

Objectives: By the end of this assignment, learner will

• Describe the appropriate processes to follow in the nursing intervention of medication administration (Developing Nursing Judgment).

• Identify the role of nursing and other inter-professional team members in providing for safety and high quality patient care (Developing Teamwork and Collaboration).

• Verbalize increased awareness of medication errors, and state 3 or more ways to improve patient safety in this case study (Developing Nursing Reflection).

• Express individual perspectives and considerations impacting individual honesty and integrity with regard to reporting of medication errors (Developing an Ethical Identity).

Directions:

1. Watch the videos listed below, and read the timeline of events • Medication Error Kills a Vanderbilt Patient video

(https://www.youtube.com/watch?v=FIeYsJywO00) • Ex-Vanderbilt Nurse Charged with Reckless Homicide

(https://www.youtube.com/watch?v=PzV6coXvYsE) • Timeline: https://www.tennessean.com/story/news/health/2020/03/03/vanderbilt-nurse-

radonda-vaught-arrested-reckless-homicide-vecuronium-error/4826562002/ 2. Read the details of the case below and reflect and answer the questions below. 3. Responses should be detailed and address all components of each question. Responses should be

articulated at the college level and include complete sentences, proper punctuation, and proper grammar. Responses must be typed and submitted in a Word document.

4. Upload into Canvas  Assignments  Preventing Medication Errors

Overview of events

On Dec 24, 2017, the client presented to the Emergency Dept at Vanderbilt University Medical Center and was diagnosed with a Subdural Hematoma (bleeding in the brain). Over the course of 2 days, the client’s condition improved, and discharge to home was anticipated on Dec 26 after a follow up radiology scan to compare to prior results. In anticipation of the scan, the patient received a dose of contrast medication and was sent to the radiology department.

Due to client history of anxiety, and concerns with claustrophobic sensations, an order was obtained from the Neuro ICU physician for Versed to be administered to reduce anxiety. The administering nurse reported that she understood this needed to occur expediently, so that the test could proceed. There was a medication error during the administration process, that was discovered on the same day. The client experienced hypoxia and brain death, ultimately leading the family to remove the life sustaining equipment. Death was pronounced on Dec 26, 2017.

Background

The Centers for Medicare and Medicaid Services (CMS) Report & Corrective Actions can be viewed HERE, where the events are described via interviews with the involved parties. The CMS report states, “the hospital failed to ensure patients' rights were protected to receive care in a safe setting and implemented measures to mitigate risks of potentially fatal medication errors to the patients receiving care in the hospital” (CMS, 2018, p. 1).

CMS defined the nurse’s role in medication administration from a review of Lippincott Manual of Nursing Practice 10th Edition "…Watch the patient's reaction to the drug during and after administration. Be alert for major adverse effects, such as… respiratory distress… NURSING ALERT… The nurse is ultimately accountable for the drug administered…" (CMS, 2018, p.3). Also, CMS defines neglect as the failure to provide goods and services necessary to avoid physical harm. (CMS, 2018)

At Vanderbilt policy is as follows… “…Medication orders are reviewed by a pharmacist prior to removal from floor stock or an automated dispensing cabinet unless…A delay would harm the patient (including sudden changes in a patient's clinical status…(CMS, 2018, p.3).

“The medication Vecuronium (a neuromuscular blocking medication that causes paralysis and subsequent death if not monitored accordingly) was listed in the policy as a high alert medication. There was no documentation in this policy detailing any procedure or guidance regarding the manner and frequency of monitoring patients during and after medications were administered” (CMS, 2018, p.3).

Per CMS the “Administration of midazolam (Versed) requires an experienced clinician trained in the use of resuscitative equipment and skilled in airway management…Monitor patients for early signs of respiratory insufficiency, respiratory depression, hypoventilation, airway obstruction, or apnea (i.e., via pulse oximetry), which may lead to hypoxia and/or cardiac arrest” (CMS, 2018, p.5).

At Vanderbilt, “There was no documentation in this policy detailing any procedure or guidance regarding the manner and frequency of monitoring patients during and after medications were administered” (CMS, 2018, p.7).

The Interview

Telephone interview with RaDonda Vaught on 11/5/18 beginning at 4:41 PM, RaDonda was asked to describe the circumstances leading up to the Patient’s death on Tuesday 12/26/17. RaDonda stated,

"I was in a patient care role, I was the "help-all nurse". A help-all nurse is a resource nurse; and I had an Orientee… The primary nurse asked me to go downstairs to PET scan and give the patient Versed because [the patient] was not able to tolerate it [the PET scan procedure] or they would have to send her back and reschedule it. We were already heading to ER to do a swallow study on a patient. I went and searched for the med under [the patient's] profile [in the ADC (automated drug cabinet)] and it was not there. I chose the override setting and I searched for it. I was talking to the Orientee about why we do swallow studies in the ER…I typed in the first 2 letters [VE] and that's how I hit it, I chose the 1st one on the list. I took out the vial and I looked at the back at the directions for how much to reconstitute it with, I did not re-check the name on the vial… I saw 1 patient on one of our beds, I checked the patient for her identity, and told [the patient] I was there to give her something to help her relax… I reconstituted it and measured the amount I needed… One of the Radiology Technicians came out, I gave the med, flushed it and we left. The Radiology Technician took the patient back. We went straight to the ER from there… I am not sure if I drew up and gave him/her what she needed… heard a rapid response call for PET scan. That was a red flag since the patient was ours… we were being responsible to go to see if it was our patient… when we got there, they had intubated her and got a pulse back. The Physician, Charge Nurse, myself and the team, we collectively moved her bed back to the unit. I told the Physician that I had given [the patient]

Versed a few minutes ago…I reminded the Nurse Practitioner that the Patient was awake but unmonitored when I gave her the Versed. We spent probably about 45 minutes getting labs and things. I had drawn several tubes of blood for labs when another RN came up to me and she said, "Is this the med you gave her?" I said yes, we need to waste it. The RN stated, "This isn't Versed" I said what is it? she said, "It's Vecuronium" and I went back into the patient’s room and the Physician, a couple of residents, and the Nurse Practitioner were in the room discussing what was happening. I told them right then it was my mistake. I told them I gave Vecuronium. They all knew it right then. The Nurse Practitioner said, "I'm so sorry" and I left the room. I am not sure where I went but I ended up in the educator’s office. I spoke to management – different people. I filled out the "Veritas" [Hospital's reporting system]. This was around four-ish [4:00 PM]. I gave both my phones to the charge nurse and the Orientee was assigned to someone else. It was after 8:00 PM when I left."

RaDonda was asked if she documented the Vecuronium in the Patient’s medical record. RaDonda stated, "I did not. I spoke with my Nurse Manager, and she told me the new system would capture it on the MAR” [Medication Administration Record]. RaDonda stated that she left the patient with a Radiology Tech. RaDonda confirmed that she did not monitor the Patient after the medication was administered (CMS, 2018, p. 23-26).

Pictured above are the two medications in question.

CMS Report & Investigation

The CMS report from the event describes the incident, thusly:

“The patient was scheduled for a PET scan at 2:00 PM. No documentation when the Patient arrived in Radiology. An order for Versed was entered into the computer at 2:47 PM and was verified by Pharmacy at 2:49 PM. (Versed was available at 2:49 PM under the Patient’s profile) An override pull for Vecuronium was documented at 2:59 PM. There is no documentation of the administration time or amount of Vecuronium to the Patient. RaDonda stated it took about 5 minutes to get to Radiology before he/she administered it. The Patient was found unresponsive and pulseless in the Radiology Department prior to the PET scan. A rapid response was called overhead at 3:29 PM. (30 minutes between the time the drug was pulled from the ADC (automated drug cabinet) in Neuro Unit and the time the rapid response was called” (CMS, 2018, p. 21).

Review of a physician note dated 12/26/17 at 3:45 PM revealed the physician documented, "Called for code in PET scanner, patient was pulseless and unresponsive on arrival. patient was emergently intubated and retrieved ROSC [return of spontaneous circulation] after 2 – 3 rounds of chest compressions. Patient transferred to Neuro ICU."

The decision was made to withdrawal care on 12/27/17. “Telephone interview with the Director of Investigations (DOI) at the Medical Examiner's Office on 11/5/18 at 10:01 AM, the DOI was asked about the Patient and what was reported to them regarding the Patient’s death. The DOI stated, "The date of death was 12/27/17 and was called in by the Physician. He stated that maybe there was a medication error but that was just hearsay, and nothing has been

documented in the medical record. There was no named drug in the notes. The death certificate says the Patient had a bleed. We declined jurisdiction because there was an MRI that confirmed the bleed…" (CMS, 2018, p. 23).

• Medical Examiner Report regarding cause of death for the client, AMENDED (original did not include Vecuronium information, which was discovered later).

More than 10 months passed, with no report of this sentinel event to federal authorities (as required by law). In October 2018, an anonymous report to CMS then triggered an investigation into this incident.

Facility Response (after discovery 10 months later)

“As a group [leaders, risk etc.] what can we do to fix it… Action plan: The bar code scanning implementation in Radiology – this is pending. A Multi-disciplinary team meeting regarding the override med list. Vec [Vecuronium] was removed from override status…" (CMS, 2018, p.22).

Current Situation

The initial board of nursing reviewed case in 2018 and decided to not revoke RaDonda’s nursing license. RaDonda Vaught was arrested in February 2019 and charged with reckless homicide, abuse of an impaired adult, and failing to maintain an accurate patient record for making a medical mistake that resulted in an elderly patient's death (NPR, 2019). RaDonda plead not guilty to these charges.

• Timeline: https://www.tennessean.com/story/news/health/2020/03/03/vanderbilt-nurse-radonda-vaught-arrested-reckless-homicide-vecuronium-error/4826562002/

However, in 2019, the Tennessee Board of Nursing decided to reverse its prior decision and conduct a disciplinary hearing regarding this matter.

• Tennessee Board of Nursing Hearing (July 22, 2021) with RaDonda Vaught, BSN testimony (beginning at 03:51:00 in the video) https://tdh.streamingvideo.tn.gov/Mediasite/Play/d4e0d6b971de40a7a361928bd1528e291d

• Institute for Safe Medication Practices (ISMP) wrote an article on the topic: TN Board of Nursing’s Unjust Decision to Revoke Nurse’s License: Travesty on Top of Tragedy! https://www.ismp.org/resources/tn-board-nursings-unjust-decision-revoke-nurses-license-travesty-top-tragedy

This Tennessee Board of Nursing hearing on July 22, 2021, resulted in a decision to revoke the RN license previously granted to RaDonda Vaught and levy a fine of $3000 to Ms. Vaught for failing to appropriately maintain patient safety.

The Davidson County, Tennessee criminal charges were set for a trial date of July 2020. However, due to COVID-19 pandemic, a postponement was granted. At this time the trial is scheduled for March 2022.

• Family of Woman killed by medication mix-up speaks out against the criminal charges https://www.wsmv.com/video/family-of-woman-killed-by-medication-mix-up-speaks-to-news4/video_84113166-4ff5-52ec-bdc6-2440c3754e82.html

• Case Status with Davidson County, Tennessee Criminal Courts: https://sci.ccc.nashville.gov/Search/CriminalHistory?P_CASE_IDENTIFIER=RADONDA%5EVAUGHT%5E01251984%5E586540

References

Centers For Medicare & Medicaid Services (CMS). (2018). Statement Of Deficiencies And Plan Of Correction. https://www.documentcloud.org/documents/6535181-Vanderbilt-Corrective-Plan.html

Centers For Medicare & Medicaid Services (CMS). (Oct 3, 2018) Anonymous Complaint https://www.documentcloud.org/documents/6542003-CMS-Complaint-Intake.html

Ex-Vanderbilt Nurse Charged with Reckless Homicide (2018) https://www.youtube.com/watch?v=PzV6coXvYsE

Ex-Vanderbilt nurse RaDonda Vaught loses nursing license for fatal drug error (July 23, 2021). https://www.tennessean.com/story/news/health/2021/07/23/ex-vanderbilt-nurse-radonda-vaught-loses-license-fatal-error/8069185002/

Family of Woman killed by medication mix-up speaks out against the criminal charges https://www.wsmv.com/video/family-of-woman-killed-by-medication-mix-up-speaks-to-news4/video_84113166-4ff5-52ec-bdc6-2440c3754e82.html

Institute for Safe Medication Practices (ISMP) (Aug 21, 2021) TN Board of Nursing’s Unjust Decision to Revoke Nurse’s License: Travesty on Top of Tragedy! https://www.ismp.org/resources/tn-board-nursings-unjust-decision-revoke-nurses-license-travesty-top-tragedy

Medical Examiner Records (Dec 27, 2017) https://www.documentcloud.org/documents/6540657-Charlene-Murphey-ME-Investigation.html

Medication Error Kills a Vanderbilt Patient video (2018) https://www.youtube.com/watch?v=FIeYsJywO00

NPR Choice page. (2019). Npr.Org. https://www.npr.org/sections/health-shots/2019/04/10/709971677/when-a-nurse-is-prosecuted-for-a-fatal-medical-mistake-does-it-make-medicine-safe

Tennessee Board of Nursing Hearing (July 22, 2021) https://tdh.streamingvideo.tn.gov/Mediasite/Play/d4e0d6b971de40a7a361928bd1528e291d

The RaDonda Vaught case is confusing. This timeline will help. (July 23, 2021 update) https://www.tennessean.com/story/news/health/2020/03/03/vanderbilt-nurse-radonda-vaught-arrested-reckless-homicide-vecuronium-error/4826562002/

Learner Name: _____________________ Clinical Section: __________ Date Completed: _____________

Clinical Reflection Questions for Learners

1. Identify at least 5 errors RaDonda made when administrating medication.

2. Identify anyone else who could be at fault in this case and state why.

3. What was RaDonda’s responsibility to monitor the patient after giving the medication?

4. Do you think RaDonda took the correct action once the medication error was identified? Please explain your answer.

5. Do you think the hospital took the correct action after the medication error was identified? Please explain your answer.

6. Do you think a nurse should be criminally liable for a medication error? Please explain your answer.

7. How does this change your feelings on passing medications to patients?

8. Do you think medication errors are 100% preventable? Why?

9. What will you do in your practice as a nurse to help prevent medication errors?