If you are a nurse, you have probably heard about this case where a nurse from TN (Vanderbilt Medical Center) gave the wrong medication to her patient. Versed was ordered to settle an agitated patient during an MRI. The nurse was called and told to bring down the medication as soon as possible. She rushed to get the medication, and instead of giving Versed, she gave vecuronium, a paralytic medication. The patient died.
This situation is a nightmare every nurse fears and prays will never happen to them. RaDonda Vaught, the nurse who gave the medication, admitted and reported the error as soon as she realized what she had done. As a result of a split-minute decision, she will live with this error on her mind for the rest of her life.
As a nurse who worked in the ICU, ED, Medical-Surgical unit over my 40-year career, I know medical errors happen. I know I made errors and I was fortunate no one ever died, but I remember them to this day as they were mistakes I made and was sorry for them. I can only pray for RaDonda as she is in a living hell as a result of a mistake. I thought I would share this story this week as it will be a landmark decision for the nursing profession. Nurses across the country/world will take this case to heart. Many will leave and all will be forever worried….as they know – this could be them and is it worth it? A very sad day for nurses, patients and the entire healthcare team.
I pray for RaDonda and the Judge who will issue the verdict on May 13 in a TN Courtroom. I hope the Judge considers the human factor that played into this situation and the impact this incident will have on the professional of nursing and the healthcare industry as a whole. Yes, she made a mistake. She did not do it maliciously or set out to murder the patient. She rushed to get the medication and did not follow the 5 R’s, which every nurse learns in nursing school, which are to make sure that you are giving the right drug, the right route, and the correct dose to the right patient.
I understand she has apologized to the patient’s family, and as I understand it, they have forgiven her.
As a nurse risk manager, the most important thing I stressed in the hospitals I worked at was reporting the error as soon as possible so the patient could be treated. Also, I wanted to talk to all involved early to get the facts while everything was fresh in people’s minds. Doing so allowed me to put the case together so we could look at strategies to prevent the mistake from being repeated.
In healthcare, we call this a culture of safety which means when an error occurs, the person committing the mistake feels safe to report the incident. A ‘Just Culture’ environment is a critical concept experts attribute to reducing medical errors throughout healthcare. If the verdict is upheld, this decision will set that process back as all healthcare professionals will be fearful of reporting an error due to what could happen to them.
I am sorry for the patient; I am sorry for the family, and I am also sorry for RaDonda Vaught and her family. I am also sorry for every nurse who works in today’s comprehensive healthcare system. I fear we will see a mass exodus because of this verdict, making healthcare unsafe for everyone.
In my opinion, I would have liked to see RaDona’s license taken away as she did not follow the basic tenets of nursing. She needs education and mental health counseling to help her through this. I would also like to see the Judge order her to go around the country to remind nurses how deadly mistakes can occur by not following protocols. I would like to see Vanderbilt University Hospital do the same type of education as these types of errors are system errors. No one person is responsible. What process did they follow to investigate the error, and what changes did they make to ensure the same error does not occur again? Learning this would help other settings to look at their systems and help to educate their staff as to the importance of following procedures.
I want the Judge to use this case as a learning exercise so that we as an industry, all in healthcare become more aware of how easy it is to make a fatal medical error in which we all are at fault.
In my mind, this was not a criminal act but a mistake that took a life. If there was not a ‘category’ under the law’ to put this mistake under, the legal system must find another name for this type of incident. Still, criminally negligent homicide does not seem like the correct label to put on this. It makes the nurse out to be a monster – not a human who made a mistake.
I encourage all nurses to stay on top of this case and be very careful while doing their job, as what we do is a matter of life and death’.
Here are some articles you can read to learn more about the case and what we need to do to prevent medical errors from being repeated.
- NPR: Former nurse found guilty in accidental injection death of the 75-year-old patient. Click here to read the story.
- NPR: In the nurse’s trial, the witnesses say the hospital bears ‘heavy’ responsibility for patient death. Click here to read the article.
- Statement from the American Nurses Association on the verdict. Click here to read more.
- Medical Error Reduction and Prevention: An education program on Medical Error and Reduction Prevention. Click here to read more.
- Ilene Corina, Patient Safety Advocate and President and Founder of Pulse Center for Patient Safety Education and Advocacy, wrote an article on the incident. To read the article, click here.
If you have any questions, please feel free to email me at allewelly48@gmail.com
Anne, this is such a serious topic and I agree that the nurse is not the only one responsible. There are many system issues that allow errors to be made. The electronic health record, (EHR) can enable errors made by those (MD, PA, NP) who order medications. In my role as Peer Review Analyst, recognized medication errors came to me as ‘event reports’. One glaring system problem was that medication orders for ED patients ‘expired’ after 2 months. A PA had ordered an antihypertensive by mistake. Both meds began with the same two letters and he selected the wrong one from the list. The patient returned to the ER d/t dizziness and the error was found. By the time this error had been thoroughly researched and brought to committee the medication order was no longer on the chart. The EHR company assured me that this was the way it was intended to work. I was shocked! That hospital now uses a modern and robust EHR, and I hope that orders do not ‘expire’.
Wow. Thanks for sharing your thoughts.
When I worked bedside nursing, it was instilled upon us to report all positive and negative actions, taking the consequences as they fall/are judged.
Prayers for DaRonda.
A nurse who says she never made a mistake is scary, she doesn’t know she did. Investigating multiple errors as Director of Nursing revealed a chain of system issues resulting in the nurse as the final step incurring the blame. Encouraging self reported errors has finally benefiting patient care. This will set self-reporting into the dark ages. Thank you for this blog!
“Reckless homicide and abuse”– a label that DaRonda will be burdened with her for the rest of her life. I hope someday she will forgive herself and I spray that the judge will consider her value to society and be merciful as he “dispenses justice” While she is culpable admittedly so, I have to ask what hospital policies, procedures and systems were in place to ensure patient safety also ensure that staff RNs are appropriately educated and supported in performing their jobs. So sad that the hospital has turned their backs on DaRonda in avoidance of their admission of fault and a lawsuit. Like it or not they will stand with her in the civil suit.
Anne thank you for sharing this. I too have posted this story on all of my social media and spoken to a number of nurses who didn’t even know about this case. It’s critical to continue to share this to make all healthcare workers aware that they may be next!! We nurses need to continue to support DaRhonda! We need to ask our professional organizations to help defend her. Yes her license should be taken away but darned if that hospital just threw her under the bus. I would love to see cms penalize that hospital.
I appreciate your insights and wisdom here, Anne and that you are building a bridge with consumers. I especially like your ideas on trying to make constructive learning/teaching opportunities out of the tragedy.
I’ve made mistakes too and it is such an awful feeling. Blaming one person is egregious in and of itself.
Also, thanks for the resources. I’d like to add two:
Shortcuts in Medication Administration
https://www.confidentvoices.com/2013/02/04/dangers-shortcuts-medication-administration/
Transparency, Compassion, and Truth in Medical Errors
https://youtu.be/qmaY9DEzBzI
***THIS IS FROM RADONDA HERSELF***the nurse who gave the wrong medicine. If you want to help read this email ad it has information on the process
If you would like to help, you can write a letter for the judge at my public sentencing hearing on Friday, May 13th at 9am. Ironically, that falls during Nurses Week & is the day after the Million Nurse March. (Info for coming in person is at the end of these instructions).
I would ask that you please read the following instructions completely prior to writing your letter, there are many important details to consider… please, read them all carefully and completely prior to writing your letter!
Two types of letters would be appropriate, depending on whether you know me or not: CHARACTER LETTERS for those who know me; for those who do not, a professional letter addressing the impact of this case and sentencing.
HANDWRITTEN if possible, I believe it will more accurately display the vast degree of personal impact that the outcome of this verdict has had on each of you as individuals and the impact her ruling of sentencing will also have on each of you individually.
All letters should be mailed directly to me: RaDonda Vaught
P.O. Box 128
Bethpage, TN 37033
Peter gave me a great format to follow, see the very end of these instructions… A similar one can be found online here: https://thelawdictionary.org/…/best-way-to-write-a…/ https://thelawdictionary.org/…/best-way-to-write-a…/
Judge Smith’s information for addressing her in this letter can be found in the link below, but please mail the actual letter directly to me. Let’s not overwhelm her office.
I can have them all submitted to the court for consideration at one time. ALSO, Judge Smith does not work for the DA, nor is she responsible in any way for their presentation and prosecution of this case nor the jury’s verdict. She is responsible for presiding over the court proceedings and she will ultimately be responsible for my sentencing. Please be considerate and respectful towards her, and the process over which she presides in your letters. https://www.tncourts.gov/…/circuit-criminal…/judges/ jennifer-l-smith
ADDITIONALLY: No dissing the DA or the assistant general district attorneys. We don’t need to stoop to their level to make a point. . We are a community of healthcare PROFESSIONALS & our actions need to indicate that… remember, this whole case is about Just Culture, where our actions and doing the right thing speak louder than our words.
You can be professionally critical of the contributing systemic issues, your concerns of impact on patient safety, and your concerns of how Tennessee law was violated in the release of protected documents (specifically my very detailed 4 page incident report, which was to be protected by law-see the links for the statues below regarding reporting, as well as patient safety and quality improvement) but again, please keep it respectful & classy.
Tennessee Code Annotated 68-11-211
Tennessee Code Annotated 68-11-272 Tennessee Code Annotated 63-1-150
Honorable Judge Jennifer L. Smith Davidson County Criminal Court Division IV
Re: RaDonda Vaught Case No: 2019-A-76
Honorable Judge Smith,
For Character letters, 1st paragraph should identify yourself, what you do for a living and how you know me. See these tips: https://thelawdictionary.org/article/best-way-to-write-a- good-character-witness-statement/
and these: https://thelawdictionary.org/…/best-way-to-write-a… judge/
The remaining balance of the letter should include the positive attributes possessed by me. Any individual stories are welcome.
Keep the politics out of it and keep it classy! Respectfully,
Your Name
Your phone number Your address
your email
Details of Sentencing hearing on May 13, 2022 @ 9am:
The Justice A.A. Birch Building is located at:
408 2nd Avenue North, Nashville, Tennessee 37122 https://gscourt.nashville.gov/general…/maps-directions/
Parking is located underground at Public Square Parking, 101 James Robertson Parkway,
Nashville TN 37122
The sentencing hearing will be held in courtroom 6D (6th floor).
NO SIGNS INSIDE THE COURTHOUSE.
NO PROTESTING INSIDE THE COURTHOUSE.
Cellphones ARE allowed, as are snacks and plastic drink containers (NO metal).
The courthouse doors are generally opened shortly after 7am, even though the website indicates it opens at 8am. I would recommend getting there to get through security prior to 8am.
I will most definitely write a letter for RaDonda on behalf of all nurses. We’ve all been there in her spot if we’ve practiced long enough. There should be implications for Healthcare Administrators across the country that don’t allow enough time to give meds properly, or that understaffed habitually because they know we nurses, will somehow ‘get it all done’. No other profession has such little administrative support for allowing enough time for all the tasks that our patients need us to do. No other profession has so little control over the timing of our activities. Most other professions are appointment only and they bill by the minute, which ensures they can accomplish all their duties safely. We need some reform on expectations of nurses and some reasonable time allowances so care can be safely done.
The saddest part of this case is the precedent it will set. Lives will be lost as nurses everywhere will choose to NOT report mistakes. The choice will be to cover up or ignore the mistake for the chance at “getting away with it”. The other option, immediately reporting the error, now comes with handcuffs and a homicide charge. Nurses are incredible people and most are in the highest echelon of morality, but what nurse won’t think twice now about losing their freedom. Their children losing a parent. Their spouse losing their life partner.