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.

  1. NPR: Former nurse found guilty in accidental injection death of the 75-year-old patient. Click here to read the story.
  2. NPR: In the nurse’s trial, the witnesses say the hospital bears ‘heavy’ responsibility for patient death. Click here to read the article.
  3. Statement from the American Nurses Association on the verdict. Click here to read more.
  4. Medical Error Reduction and Prevention: An education program on Medical Error and Reduction Prevention. Click here to read more.
  5. 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

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