Despite numerous advances in anesthesia safety over the years, former Tennessee nurse RaDonda Vaught's deadly medication error could have been prevented with a few system-wide fixes that aren't that difficult or costly. Certainly, criminalizing her mistake and charging her or any other nurse with negligent homicide and neglect was absolutely the wrong approach.
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Feds said Vaught wasn't the only one who erred; hospital had four "immediate jeopardy" flaws ...
I work outpatient. There are no medications on the premises that could possibly do serious harm. And yet, Every Single Task I perform using our eMR gives me a series of bright red warnings. “This patient is on Prozac. RISK FOR SEROTONIN SYNDROME. DO YOU REALLY WANT TO SEND THIS MED.” “This patient is on warfarin. DID YOU DISCUSS BLEEDING DANGERS.” “This patient has a history of depression. DID YOU ASSESS FOR SUICIDALITY.” I have to click “acknowledge” multiple times on bright red warning boxes to accomplish the simplest of tasks. When someone says “But RV overrode a paralytic warning!” I just roll my eyes.
I was always sympathetic to the fact that Radonda overrode the Pyxis warning. THAT I can relate to, and agree 100% with Emergent on THAT being a huge problem.
If only that had been the only thing. If only she had then looked at the vial and said, "? how did I end up with vecuronium in my hand?! "
Specializes in Nurse Leader specializing in Labor & Delivery.
On 6/18/2022 at 7:57 AM, ThePrincessBride said:
I don't think a med like vec should he easily accessible. It should require two nurses to pull and 2 nurses to give or it needs to be Stat or ordered from pharmacy.
I mean, if you have to double sign heparin drip changes, you should have to dual sign a paralytic.
It’s needed an emergent situation for RSI. Requiring pharmacy or to nurse nurse sign off would put people in danger.
Yes, it does boil down to the simple fact that all nurses need to look at the medication, and verify that they are giving the correct one. I've caught myself before by reading the vial. I looked at it and said "Oh I took the wrong medication out, how could that have happened? I had better put it back and start over!"
mtmkjr, BSN
577 Posts
I was always sympathetic to the fact that Radonda overrode the Pyxis warning. THAT I can relate to, and agree 100% with Emergent on THAT being a huge problem.
If only that had been the only thing. If only she had then looked at the vial and said, "? how did I end up with vecuronium in my hand?! "