A recent release from the Tennessee Bureau of Investigations reports that two years ago, a patient at Vanderbilt University Medical Center in Nashville, Tennessee, died because they had allegedly been given the wrong medication by nurse RaDonda Vaught.
Details of the incident were not revealed publicly until last November in a federal investigative report, and since, Vaught has been indicted on charges of reckless homicide and impaired adult abuse.
The fatal mistake occurred when the patient’s doctor prescribed Versed, a common anti-anxiety drug that was meant to calm the claustrophobic patient during a CT Scan. The nurse Vaught was ultimately responsible for retrieving the medication from the hospital’s automated dispensing cabinets (electronic drug storage for medication) where she claims she was unable to find the medication “Versed” using her profile in the system.
In response to this, she did a commonplace override of the system to access more powerful drugs outside her profile and, while talking to an orientee she was training, typed in “VE” and chose the first drug she found on the list.
Instead of Versed, she grabbed the powerful paralytic drug vecuronium, a drug used to keep patients still on the operating table in low doses, but also used in the three drug cocktail used to execute death row inmates in some states. Vaught confirmed in the report she did not re-check the name on the vial.
While the Tennessee Department of Health saw no reason to take legal action against Vaught or even suspend her nursing license, it is justifiably terrifying to think that instead of a simple anti-anxiety drug, one might get a paralytic in its place.
To prevent incidents of this caliber from occurring, nurses have protocols in place with patient’s safety in mind and to decrease the possibility of making an error that would harm the patient.
One of these practices is the Five Rights of Medication in which, a nurse is supposed to consider five things before they give a patient any medication: right medication, dose, route, time and patient. It’s hard to believe Vaught went through this process before administering the fatal dose of vecuronium to the patient.
Had she gone through this process, one that all nurses in the United States are taught, she would have realized “Versed” and “vecuronium” were not the same drug. She may instead have tried searching for the drug “Versed” under its generic name, midazolam.
This is problematic because Vaught’s error is not rare. Medical errors are the third leading cause of deaths in the United States.
According to a study done by John Hopkins, more than around 250,000 deaths per year in the U.S. are caused by medical errors, only behind heart disease and cancer. The researchers behind this study argues medical errors should not be met with legal action or punishment.
They state most medical errors aren’t caused by inherently bad staff, but more often than not are caused by systemic problems in the medical field that increase the likelihood of a mistake being made. Such as lack of coordination in a patients’ care and the under use of safety protocols.
In regard to Vaught’s error, the researchers are correct. Whether intentionally or not, she omitted using safety protocols as a part of the medicinal administration process and killed a patient.
The medical fields refusal to address the overwhelming amount of deaths caused by medical errors is a lack of accountability. A quarter of a million people die every year because of the mistakes of medical providers, which means roughly a quarter of a million families suffer every year after trusting doctors and nurses with their family member’s life.
Nurses from across the United States have rallied around Vaught, claiming that anyone was capable of making a mistake. While it is understandable that making mistakes is a part of human nature, it is unacceptable to refuse to take action against medical professionals who omit safety protocols.
Medical professionals literally have patients’ lives in their hands, therefore they must be held to a higher standard. It should not be commonplace that nurses choose not to abide by rules and protocols. It should not be commonplace that patients die because of mistakes and lack of attention.
While federal charges have been made, it’s crucial that the medical field address this issue internally as well. It shouldn’t take an investigation to years after the incident to address an issue. All medical professionals should be held accountable for this kind of direct lack of judgement and the field should use this as a way to create better policies in the future.