Beyond the RaDonda Vaught Case: Avoiding Medication Administration Errors

By now you have heard, read, and experienced various emotions about the jury conviction of former nurse RaDonda Vaught of criminally negligent homicide and impaired adult abuse after mistakenly administering the wrong medication to a patient in the PET scan unit, which resulted in the patient’s death.

The nurse also lost her RN license prior to the conviction.

Many articles and other news coverage methods have focused on the RaDonda Vaught trial. In addition, the American Nurses Association (ANA) and the Tennessee Nurses Association (the state affiliate of the ANA and the state within which she practiced) issued a response to the conviction.

I thought it best not to focus this blog on comments and media coverage about the trial. Besides, I’m sure you have your own thoughts about the reported facts of the case and what ensued afterward.

Rather, I would like to highlight how you can hopefully avoid being in her shoes through a review of some medication administration principles that minimize the errors that reportedly occurred during her mistaken administration of the wrong medication.

Some Principles for Medication Administration

The following list is based on standards of practice and standards of care for medication administration. Each is important in and of itself and should be utilized every time medication is poured and administered.

At any one time, one of the items may be more important than the others, but all need to be given undivided attention when undertaking the extremely important, but risky, task of medication administration.

  • Always adhere to the “rights” of medication administration: right patient, right medication, right dose, right time, right route, right assessment of the patient before administering, right evaluation of the patient after the medication is administered, and right documentation.

Obviously, the nurse did not meet the right medication requirement which proved to be a fatal failure. Additionally, she did not evaluate the patient after the administration of the wrong medication. Rather, she left the patient after the drug was administered.

  • Access and administer medications without distractions.

According to one article, the CMS investigation revealed that the nurse was talking to a new nurse she was precepting about a Swallow Study they were going to do next at the time she typed the medication into the automated dispensing system.

  • Always check the label on the medication against the medication order, visually inspect the medication vial or other container, and ensure that the medication has not expired.

According to the Tennessee Bureau of Investigation report, the nurse did check the Versed order with the patient’s MAR, but only looked at the back of the vecuronium bromide container, and thought it “a little odd” that she had to reconstitute the medication.

  • Utilize mindfulness during the medication administration process by being aware and taking a thoughtful approach to clinical decision-making and error interruption.

The nurse’s job title was a “help all” nurse, meaning that she helped provide nursing care for “urgent or emergent” needs when nursing staff could not do so. She was asked to go to the PET scan unit …read more

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