The Case
RaDonda Vaught was a 39-year old registered nurse serving as the "help-all" nurse (for which there is no specific job description) at Vanderbilt University Hospital on Dec. 26, 2017. She also had an orientee. She was asked to go down to Radiology PET scan and administer the medication Versed to 75-year old Charlene Murphey who had been hospitalized for a subdural hematoma, because she was not able to tolerate the PET scan procedure or else they would have to send the patient back and reschedule it.
She pulled the medication from the Pyxis and put the medication vial in a baggie and wrote on the baggie, "PET scan, Versed 1-2 mg" and went to Radiology to administer the medication to Murphey. Since she had never been to PET scan before, she had to ask for directions, and once she found it, she checked the patient for her identity, and told her she was there to give him/her something to help him/her relax. She administered the medication and then left the area without continuing to monitor the patient.
The Errors
The facts currently understood in this case show that Vaught committed at least ten errors when administering the medication to her patient. These errors include, but are not limited to:
-Searching for the medication by trade name instead of generic, despite being trained to the contrary.
-Selecting vecuronium instead of midazolam or Versed, even though she reports that she was looking for Versed.
-Overriding the warning indicating a none-prescribed medication had been selected (potentially could be excused given the documented EMR issues at Vandy) five times
-Ignoring a warning that the selected medication was a paralytic.
-Failing to note the red all-caps paralytic warning on the cap.
-Failing to note that the medication name on the vial did not match what was ordered or what she was looking for.
-Failing to take action to further verify the medication after noting that the medication was in powdered form when the prescribed medication should have been packaged in liquid form (by her own admittance, she found this “odd”).
-Following the instructions for reconstitution on the vial again without noting that the medication name did not match what was prescribed and that the concentration did not match what was commonly carried in the hospital.
-Actually administered the wrong dose of the wrong medication (1 mg vecuronium instead of the ordered 2 mg versed).
-And, last but not least, failing to monitor the patient, even briefly, for any adverse effect after administering the medication.
The Outcome
Within the hour, the Transporter found the patient unresponsive and the Radiology Technician called a rapid response and started CPR. By the time Nurse Vaught arrived, the patient had been intubated and the heart rate had returned to normal. Nurse Vaight told the team that she had administered Versed to the patient only a few minutes before. Vaught stated RN #2 approached him/her and asked, "Is this the med you gave Ms. Murphey?" and Vaught responded "yes." Vaught then stated RN #2 said, "This isn't Versed, It's Vecuronium." Vaught then went into Murphey's room and informed Physician #2, and the NP that she had made a mistake and administered Vecuronium to Murphey instead of Versed.
Murphey was declared brain dead on January 27th and removed from life support. She died a short time later.
So....Why Might This Be a Good Thing?
The "Go Along" Attitude
Clinicians often violate the written policies of the organization because the organization does not want or expect the written policies to be followed. Murphey's care alone required at least 20 cabinet overrides in just three days, Vaught said. "Overriding was something we did as part of our practice every day," Vaught said. "You couldn't get a bag of fluids for a patient without using an override function." https://www.wesa.fm/2022-03-22/as-a-nurse-faces-prison-for-a-deadly-error-her-colleagues-worry-could-i-be-next
When peers face criminal charges
