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Running head: MEDICATION ADMINISTRATION ERRORS

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Medication Administration Errors: Legal and Ethical Issues April 13, 2020 NUR 2140C Keiser University

Medication Administration Errors: Legal and Ethical Issues

One afternoon in December of 2017, RaDonda Vaught R.N., went to the medication room on her unit to retrieve a dosage of Versed to be administered to her patient Charlene Murphy. Charlene Murphy was an elderly woman and was scheduled for an MRI that morning, the thought of which produced some anxiety in her. The Versed that RaDonda was retrieving from the medication room was to relieve Charlene’s anxiety. Charlene Murphy never made it to her MRI appointment that day. Instead of receiving Versed, she received a dose of vecuronium bromide which is a powerful nerve blocker and paralytic and within hours, she was dead. Court records show that Ms. Vaught was precepting a new hire that day and was asked to administer medications for a patient whose assigned nurse was covering patients for a coworker that was on lunch. Ms. Vaught admitted that she was deep in conversation with the new hire when she went into the medication room and entered the name of the medication into the system, Versed, to retrieve the required dose. Instead of being listed under Versed, its trade name, the medication that was needed was listed under its nonproprietary name midazolam hydrochloride[CITATION GOr19 \l 4105 ]. Still focused on the conversation and assuming that there was some error in the system, Ms. Vaught decided to manually enter the first two letters of the medication’s trade name into the system, VE, to locate the medication. The medication that was released to Ms. Vaught was VEcuronium bromide. The medication was retrieved, mixed, and administered to the patient and both the nurse and the new hire went on their way. No member of the nursing staff checked on the patient after the medication was administered, and she was found not breathing and without a pulse by the transporter sent to take her to her MRI. Within a few short minutes, DaRonda Vaught had

made several medication-administration errors that ultimately led to the death of Charlene Murphy[ CITATION Wor20 \l 4105 ]. Though it may be difficult to say if the actions committed by Ms. Vaught were done intentionally or willfully to harm Mrs. Murphy, what is indisputable is that a death occurred due to her negligent behavior. In order to administer the wrong medication to the patient, the nurse would have had to ignore or be oblivious to the medication warning shown by the computer system, ignored her medication checks (MAR to med, MAR to chart, MAR to med to patient) and the seven rights of medication administration (Right patient, right medication, right dosage, right time, right route; the patient has the right to refuse the medication and there must be the right documentation), and failed to observe the warnings on the vial of medication itself. Finally, and perhaps most troubling, Ms. Vaught did not check on the patient, or ask anyone else to check on the patient, that she had just administered a medication that she thought was a powerful central nervous system (CNS) depressant with known adverse effects if mistakenly administered. Finally, there was no documentation of the administration of the medication in the patient’s chart[ CITATION Spr20 \l 4105 ]. It is very easy to say, in hindsight, what a person should have done in any given situation, but it is undeniable that Ms. Vaught should have devoted more of her attention to the retrieval of the needed medications instead of the conversation with the new hire. Had she done so, she might have taken the time to notice that both the computer system and the vial of medications displayed warnings about the paralytic nature of the medication she had retrieved, warnings that the medication that she intended to administer did not have. Had she performed the three medication checks or remembered her seven “Rights” of medication administration, she undoubtedly would have noticed that the name of the drug that the patient had been prescribed was Versed (midazolam hydrochloride) and not vecuronium bromide. Had Ms. Vaught been more attentive to the task at hand, she would have checked on the

patient she had just administered a medication to, and perhaps could have saved her from slowly suffocating to death. The factor that played the biggest role in the death of Mrs. Murphy was the nurse’s lack of attention to the task of medication administration. It is an accepted fact that an average of 40% of a nurse’s clinical time is spent controlling and dispensing medications, with an estimated 78% of nurses having had committed an administration error at some point during their career[ CITATION Mar19 \l 4105 ]. Given the very heavy workload that nurses consistently bear on a daily basis, it is simply an eventuality that an error will occur. The legal ramifications of this incident are still playing out in the court system. Following the death of the patient, a report was made to the county coroner that failed to mention anything about a medication administration error, because of this Mrs. Murphy’s death was classified “natural”[CITATION Kel20 \l 4105 ]. The facility where Mrs. Murphy was a patient, Vanderbilt University Medical Center, failed to report the occurrence of an administration error to state of federal officials, which is a legal requirement. Soon after the death of Mrs. Murphy the hospital settled with the family of the victim for an undisclosed sum of money and the signing of a nondisclosure agreement. On October 3, 2018 an anonymous tip led officials to uncover the story of the administration error and the death that it caused. Initially, the Tennessee Dept. of health declined to punish Ms. Vaught for the incident stating that the incident did not meet the requirements for a violation of the statutes and rules governing the profession[ CITATION Kel20 \l 4105 ]. The anonymous tip did reach the desks of federal inspectors who promptly threatened to end all Medicare payments to the Vanderbilt University Medical Center should they not implement procedures to avoid situations like this in the future. A plan was produced by the hospital with the utmost haste. Just over a year after the death of Charlene Murphy, RaDonda Vaught was arrested and charged with reckless

homicide and impaired adult abuse to which she pleaded not guilty, even though she admitted to investigators that errors had been made. Later that year, the Tennessee Department of Health changed its original decision and chose to charge Ms. Vaught with unprofessional conduct, abandoning or neglecting a patient that required care, and failing to maintain an accurate patient record. Both of Ms. Vaught’s hearings are set to begin in the early summer of 2020. Ethically, Ms. Vaught failed her patient. She did not adhere to the fundamentals of nursing practice and she failed to devote herself to the welfare of one in her care. Of the four moral elements of ethical care (attentiveness, responsibility, competence, and responsiveness), set forth by noted professor of women’s studies and political sciences Joan Tronto, Ms. Vaught practiced none[ CITATION Fow15 \l 4105 ]. She was so engrossed in her conversation that she failed to recognize that she was retrieving the wrong medication from the medication system. She shirked her responsibilities to the patient and to herself by inadequately documenting the procedure that was carried out. She displayed an incredible lack of incompetence by failing to look for the medication in the system under its nonproprietary name as well as its trade name. Ms. Vaught never even had the chance to respond to the unfolding medical crisis because she never even bothered to check on the patient after the medication had been administered. In short, the patient was not put first, nor was the patient’s expectation of competent care met. The very nature of nursing is mentally and physically demanding and can be conducive to stress, which has been proven to be a cause of medical errors[ CITATION Sab19 \l 4105 ]. Factors like rotating schedules, inadequate staffing, increasing patient load, and disorder have been proven to increase the instances of medication administration errors. Understanding that nursing is a demanding and stressful vocation, it is vital that the practicing nurse focus all attention to the task of medication administration. All other tasks

and interactions should be paused until medication has been administered and documented. Nursing managers should be conscious of the workload being placed on scheduled nurses as well as the cumulative number of hours worked in a given time period to assess nurses for signs of physical and mental fatigue. A continuing education in pharmacology as well as the medication administration systems should be undertaken by all staff members who administer medications to ensure that the most current information about the systems being used on the unit is understood by all. Nurses should place a renewed emphasis on the three checks and seven rights of medication administration to ensure that the correct medications are being administered properly. Finally patients, and the tasks being performed on their behalf, should be given the full attention of the healthcare provider to mitigate the commission of errors due to lack of concentration. In 1999 a report titled “To Err is Human” was commissioned. The purpose of this report was to shed light on the shocking amount of medical errors that were being committed every year, many of which resulting in the deaths of patients. Medical errors have been and are so prevalent in the US that there has been a concerted effort by the medical community to reduce the amount of harm done to patients as a result of preventable medical errors with several initiatives having been started in the last twenty years. There has also been a dramatic increase of involvement in the “no medical errors movement” by the general public who are becoming ever more educated about the procedures and medications prescribed for them. The most important duty of the practicing nurse it to ensure that the patients in their charge are informed about the treatment that they are receiving and are receiving the highest quality care possible. With advances in technology and a greater awareness of the issues surrounding medication administration errors, it is only a matter of time before the era of medication administration errors are a thing of the past.

References Fowler, M. (2015). Guide to the Code of Ethics for Nurses with Interpretive Statements. Silver Spring, MD, USA: American Nurses Association. Gordon, M. (2019, April 10). Shots: Health News From NPR. Retrieved April 2020, from NPR.com: https://www.npr.org/sections/health-shots/2019/04/10/709971677/when-anurse-is-prosecuted-for-a-fatal-medical-mistake-does-it-make-medicine-saf Kelman, B. (2020, March 2). The RaDonda Vaught case is confusing. This timeline will help. Retrieved April 2020, from TheTennessean.com: https://www.tennessean.com/story/news/health/2020/03/03/vanderbilt-nurse-radondavaught-arrested-reckless-homicide-vecuronium-error/4826562002/ Marques-Hernandez, V., Fuentes-Colmenero, A., Cañadas-Nuñez, F., Di Muzio, M., & Guiterrez-Puertas, L. (2019, July 24). Factors related to medication errors in the prepartation and administration of intravenous medication in the hospital environment. PLoS, 14(7), 1-12. Sabzi, Z., Mohammadi, R., Talebi, R., & Roshandel, G. R. (2019, November 15). Medication Errors and their Relationship with Care Complexity and Work Dynamics. Open Access Macedonian Journal of Medical Sciences, 7(21), 3579-3583. Spruce, L. (2020, January). Back to Basics: Medication Safety. AORN Journal, 111(1), 103112. Working Nurse. (2020, Jan 1). Medication Error or Recckless Homicide. Retrieved from WorkingNurse.com: https://www.workingnurse.com/articles/Medication-Error-orReckless-Homicide...