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Nursing Leadership 203 Preventing Medication Errors Case Study

Purpose: As a result of this activity, students will recognize the role of the nurse in ensuring

patient safety and preventing medication errors.

Student Learning Outcomes:

• Describe key attributes of electronic health record systems and their influence on patient safety and quality care.

• Critique various types of point-of-care technology and their use in the clinical setting.

• Use established criteria to evaluate the content of health-related sites found on the Internet.

• Develop professional social media interaction behaviors.

• Identify issues that affect the practice of professional nursing in the healthcare workplace.

• Describe workforce strategies that support efficient and effective quality patient care and promote improved work environments for nurses.

• Evaluate the effect of changes in the current healthcare system on nurse staffing patterns and responsibilities.

• Discuss the professional nurse’s role in promoting patient safety.

• Analyze the basis for the increasing emphasis on health care quality and medical errors.

• Use diverse technological resources to obtain information about current health policy developments and political issues.

Directions:

1. Watch the following videos:

Medication Error Kills a Vanderbilt Patient video:

https://www.youtube.com/watch?v=FIeYsJywO00

Ex-Vanderbilt Nurse Charged with Reckless Homicide video

https://www.youtube.com/watch?v=PzV6coXvYsE

https://www.youtube.com/watch?v=FIeYsJywO00

https://www.youtube.com/watch?v=PzV6coXvYsE

2. Read the details of the case. Reflect and answer the following questions in a

narrative. Responses should be detailed and address all components of each

question in a paragraph format opposed to entering answers under 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 as a Word document.

The Case of RaDonda Vaught

The telephone interview with RoDonda Vaught on 11/5/18 beginning at 4:41pm. RoDonda was

asked to describe the circumstances leading up to the Patient’s death on Tuesday

12/26/17. RoDonda 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 out

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."

RoDonda was asked if she documented the Vecuronium in the Patient’s medical

record. RoDonda 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]. RoDonda stated that she

left the Patient in Radiology. RoDonda 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.

Review of Incident

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. RoDonda 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 (Hospital term for emergency resuscitation) 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).

Action Taken After Discovered by CMS (10 Months Post Incident)

“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

RaDonda Vaught was arrested and charged with reckless homicide, abuse of

an impaired adult, and failing to maintain an accurate patient record on February 2019 for

making a medical mistake that resulted in an elderly patient's death (NPR, 2019). The board of

nursing reviewed case and opted to not revoke RaDonda’s nursing license. RaDonda plead

not guilty to these charges. The trial date was set for July 2020. Due to COVID-19 pandemic,

the trial has been postponed until March 2022.

Questions to address in your paper 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. Do you think it was RaDonda’s responsibility to monitor the patient after giving the

medication? Explain your answer.

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

Grading Rubric

Assignment