The Guilty Verdict in the RaDonda Vaught Case

Although Vaught later said she should have called the pharmacy, she opted instead to override the dispensing cabinet’s warnings. She searched again for the letters “VE” and selected the first result.

Warnings Missed

Vaught told investigators that she did not check the name on front of the vial while preparing the medication (vecuronium, unlike Versed, must be reconstituted for use), and did not realize she had inadvertently selected the wrong drug.

Photos of the vial reveal that the back label, which Vaught said she checked for reconstitution instructions, also listed the name of the drug, along with a warning that vecuronium may cause respiratory depression. The vial cap was prominently marked “WARNING: PARALYZING AGENT.”

After administering the drug to Murphey, Vaught left the patient unattended. About a half-hour later, another staff member noticed that Murphey had no breathing or pulse. Vecuronium is not a sedative, so the patient may been conscious as she gradually lost the ability to move or breathe.

“There were multiple chances for RaDonda Vaught to just pay attention,” Assistant District Attorney Chad Jackson said during closing arguments.

“Below the Proper Standard”

Throughout the trial, the defense argued that Vaught had been unfairly scapegoated for larger issues at her former hospital, including EHR problems that allegedly made dispensing cabinet overrides a common practice.

That argument did not persuade jurors (one of whom is a practicing RN) to exonerate Vaught. “The jury felt this level of care was so far below the proper standard of a reasonable and prudent nurse that the verdict was justified,” the D.A.’s office said in a statement released after the verdict.

“A Dangerous Precedent”

The verdict has drawn strong reactions from nursing organizations. A joint statement from the ANA and the Tennessee Nurses Association called the case “a dangerous precedent” and warned of “the harmful ramifications of criminalizing the honest reporting of mistakes.”

Association of California Nurse Leaders CEO Kimberly Long, RN, DHA, MSN, FNP, FACHE, fears that the risk of criminal penalties may make healthcare professionals “less likely to report their errors, which will result in significant setback in patient safety.” Vaught’s sentencing is set for May 13.

Sidebar:

The Dangers of Overzealous Autofill

Confusing medications with similar names is a frequent problem in healthcare, but, as the RaDonda Vaught case reminds us, it’s one that can have deadly results.

Too Many Similar Drug Names

According to the nonprofit organization ECRI, 92 percent of all current FDA-approved medications share the first three letters of their name with at least one other drug. Fifty-eight percent share the first five letters of their name with one or more other medications.

Add to that the fact that any given drug may have several different brand names as well as its generic name, and it becomes easy to understand how medication mistakes can occur.

Autocorrect and Autofill Errors

This potential confusion can be compounded by automated dispensing cabinets or provider order-entry systems whose autofill or autocomplete fields start suggesting drug names after the user types only a few letters.

With so many confusingly similar drug names, overzealous autofill may increase the odds of a clinician inadvertently selecting the wrong drug.

Last year, ECRI included the risk posed by autofill and autocomplete errors on its annual list of Top 10 Health Technology Hazards.

Five Letters, Five Rights

ECRI says one way hospitals can reduce the risk of autofill-related medication errors is by increasing the minimum number of characters a user must enter before the dispensing or order-entry system begins suggesting drug names.

Even if the systems used at your institution offer drug suggestions as soon as you start typing, making it a personal rule to always enter at least the first four or five letters of the medication name can help you avoid drug confusion mishaps.

Taking the extra few moments to do that, and to remember the five rights of medication administration, could be a lifesaver.

In this Article: Legal Action and Enforcement, Medical Errors, Patient Safety