When a Tennessee court found nurse RaDonda Vaught guilty of criminally negligent homicide, nurses everywhere cringed.
They could only too easily see themselves in Vaught’s shoes.
Vaught, an experienced intensive care nurse, accidentally administered vecuronium, a paralytic agent, instead of Versed to a 75-year-old patient in late December 2017. Vaught quickly realized and reported her error; the patient, though, suffered a cardiac arrest and died.
Though the Tennessee Board of Nursing initially did not recommend suspension of Vaught’s nursing license, it eventually stripped Vaught of her license. And while a jury found Vaught not guilty of reckless homicide, she was convicted of criminally negligent homicide and sentenced to supervised probation.
Vanderbilt University Medical Center, Vaught’s employer at the time of the incident, uses automated drug dispensing units to safely store medication. Nurses must digitally enter their user identification and the item (or items) requested; the electronic cabinets open only the necessary drawers, allowing nurses to access the selected items. Such systems are intended to decrease medication errors and patient harm by tightly controlling access to drugs.
By 2007, more than 80% of hospitals had implemented electronic medication cabinets. And though some research studies have noted small decreases in medication administration errors in facilities that use automated drug dispensing units, studies have also amassed multiple reports of system limitations and challenges. Because entering data for each patient is time-consuming, some nurses occasionally retrieve medication for all their patients at once, effectively bypassing some of “built-in” safety features. A 2008 study noted that nurses overrode machine-generated alerts for approximately 10% of all medications charted.
RaDonda Vaught’s patient was scheduled for a PET scan to determine the cause of a brain bleed. The patient was anxious and claustrophobic, so the physician prescribed a dose of Versed to be given pre-procedure. According to CBS News, “When Vaught could not find Versed in an automatic drug dispensing cabinet, she used an override and accidently grabbed vecuronium instead.” Vaught injected her patient with vecuronium, a paralyzing anesthetic that is used by some states for capital punishment.
The case sadly proves that “technology, in and of itself, doesn’t change behavior or keep patients safer,” says Dr. Chris Hermann, CEO of Clean Hands-Safe Hands.
Vaught was likely under stress and in a hurry when she overrode the drug-dispensing unit and inadvertently administered the wrong medication. Her patient was critically ill; the PET scan was scheduled, and staff probably needed/wanted the patient now.
Nurses around the country rallied behind Vaught because they realized that what happened to her could happen to almost anyone. The American Nurses Association (ANA) even wrote a letter to the court on Vaught’s behalf, expressing regret for the tragic loss of life as well as “regret that well-meaning nurses too often find themselves working under conditions that increase the likelihood of adverse outcomes from tragic mistakes.”
Among the “substantial grounds that exist to explain Nurse Vaught’s actions,” the ANA mentions demanding work environments characterized by inadequate staffing and complex patient needs. Such dynamic environments require rapid processing of clinical information and constant reprioritization, but rarely provide the support or infrastructure needed for nurses to function at their best.
Technology that is engineered and implemented without considering real-world clinical contexts will never effectively improve patient (or provider) safety. As researchers have noted, shortcomings in electronic medication systems’ design, implementation, and workflow integration inadvertently encourage workarounds.
Technological systems that work with people and existing clinical processes, however, can dramatically increase patient safety and contribute to optimal clinical outcomes. The Clean Hands-Safe Hands electronic hand hygiene system, which includes Adaptive Room Modes that can be adjusted to patient and clinician needs, has tripled hand hygiene performance at many hospitals and decreased healthcare-associated infections by 75%.
“It takes investments in technology, coupled with systems and processes, to not only drive behavior change but make it sustainable for staff,” Hermann says.
Nurses hope that hospital leaders will heed that advice and help them keep patients safe.
