Running Head: FATAL MEDICAL MISTAKE 1

The Case of RaDonda Vaught

Paola Molina

Mount Wachusett Community College

FATAL MEDICAL MISTAKE 2

1. Identify at least 5 errors that RaDonda made when administering the medication to

the patient?

RaDonda's first error is when she chose the first medication on the list after she types VE

and overrides the medication and ignores the two different names of the medication which are

the Doctor’s order, brand name “Versed” and the medication that she had mistaken with,

“Vecuronium”. Also she ignores the vial cap as an eye-catching red color in capital letters says:

WARNING PARALYZING AGENT. Besides, RaDonda did not monitor the patient after the

administration of the medication, as a nurse she must know that, especially if it was a medication

that she had not administered before. In addition, RaDonda did not document the medication

which was a huge fault as well; even though three years ago, there were only 5 rights and

documentation was not existing but nurses have so many places where they have to write their

assessments.

2. Is it anyone else responsible for this mistake beyond the nurse?

Yes, the doctor was the first person who was responsible for this case, because “Versed”

is a potent medication with a similar properties as Propofol, which rapidly affects respiratory

function and stops the muscles for respiration as well as has effects on blood pressure. For that

reason, the doctor needs to know all patients who are receiving this medication, are required to

be first monitored during administration and after, plus the patients who are receiving are

required to be on breathing machines or cardiac monitors and these types of drugs must be

administered by an anesthesiology or a nurse with experience in the critical intensive care unit

ICU only. Also, the pharmacist did not alert other medical personnel when that medication was
FATAL MEDICAL MISTAKE 3

dispensed. The hospital should have medication like Versed and Vecuronium at the pharmacy

with more regulations, not in a hospital dispensary machine. The pharmacy should have a better

system to override medication and with this kind of error the pharmacy should have noticed right

away with a better safety mechanism. Although, the PN made a mistake as well by sending a

relief nurse to Radiology to administer this kind of medication and the PN does not identify the

Doctor’s mistake prior to this tragic situation, as a nurse she was more than educated to be on top

of this doctor’s mistakes.

3. Who has the responsibility for monitoring the patient after giving the medication?

In my personal opinion regarding this question the nurse and the radiologist tech had the

administration mistake, The nurse because she administered the medication and the radiologist

tech because the lack in monitoring, also everything happens inside the radiology department and

both have the responsibility to assess any patient who is under their care inside that unit. The

radiology tech must be the first person who receives the information about the patient’s fear to be

in a full body scanner over her anxiety and claustrophobic reaction. As part of their job before

they start any scanner they must verify the patient identity, historical information and confirm

the patient's type of imagining. Also, the radiology tech must be in communication from start

with the patient through the whole process via intercom and always make sure that patient is

comfortable and more importantly stable.

4. The nurse took the correct action once the medication error was identified?

Yes, R.V rapid responses to her call from the radiology department. Like she admitted,

the patient was her responsibility; she helped to move the patient to the ICU; she mentioned to

the PN that R.V gave the medications as she ordered, but unmonitored. Even though a colleague

told her when she found out about R.V’s error she said “we need to waste it, this is not the
FATAL MEDICAL MISTAKE 4

Versed” R.V told the physician and PN it was her mistake, because she grabbed the wrong

medication. R.V disclosed that she administered an IV Vecuronium and left the patient

unmonitored. R.V admitted all her mistakes over the medication error, not documentation and

not monitoring the patient after the medication was administered.

5. The hospital took the correct action after the medication error was identified?

No. Vanderbilt Medical Center avoided consequence and the hospital never reported the

serious medication error to the General Public Health in Tennessee in which is required by the

law. In my opinion, the doctors were responsible to notify the patient’s family that Vecuronium

was the medication that caused the patient’s death.

6. Should the Nurse be criminally liable for medication error?

No. R.V made a fatal mistake, there is no question about that. Did she commit malpractice? Of

course. Did she violate the nurse practice act? Definitely yes. But criminal charges in this case

such as jail time and reckless homicide charges? Now that it is another level.

7. Does this change my feeling on passing medications to patients?

Yes, absolutely, starting on this responsible task with no experience with patients before,

I always feel vulnerable, and as a human being I am not perfect and not fast. I always want to

take my time to avoid mistakes and many times it is impossible. And as consequence, definitely

not only for me as a student but carrying that consciousness as a guilt all my life is even worse. I

feel that the medication checks won't be enough for me from now on.

8. Medication errors are 100% preventable?

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No. it is impossible, because computers make mistakes too, but many mistakes happen

every day in real life everywhere. We have to mention people’s personal lives and

circumstances, many medical health care staff work longer hours, do not sleep well, work two

jobs, and there are prominent medication errors at any time.

9. As a nurse student, how can I help to prevent medication error?

In my personal case, I do not want to be the fastest nurse. I want to be the safest one, I am

always going to do my medications checks, try to be focused on what I do, sleep and eat well,

and follow my instincts. Also, every time I have a new medication, I will do a small research not

only for my knowledge, but again to avoid bad events.

10. Which codes of ethics the RaDonda Case have been violated?

According to the American Nurses Association Code of Ethics for Nurses:

Provision #3: The nurse advocates and protects the rights, health and safety of the patient.

Provision #4: The nurse has the responsibility to make decisions to provide optimal patient care.

Provision #5: The nurse owes the same duties to self as to others, including the responsibility to

promote health and safety.

Provision #6: The nurse improves the ethical environment of the work setting and conditions to

conduct safety and quality health care.

Provision #7: The nurse in all roles and settings, advances the profession through research and

scholarly inquiry.

Reference
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Gordon, M. “When a nurse is prosecuted for a fatal medical mstake does it make medicine

safer?”. Health INC, April. 10, 2019. From: https://www.npr.org/sections/health-

shots/2019/04/10/709971677/when-a-nurse-is-prosecuted-for-a-fatal-medical-mistake-

does-it-make-medicine-saf

Kelman, Brett. “ The RaDonda Vaught case is confusing. This timeline will help”. The

Tennessean, Nashville, Mar. 2, 2020. From:

https://www.tennessean.com/story/news/health/2020/03/03/vanderbilt-nurse-radonda-

vaught-arrested-reckless-homicide-vecuronium-error/4826562002/

News Channel 5 [ newschannel 5]. (2019, February 20). Ex-Vanderbilt nurse charged with

reckless homicide enters not guilty pleaded [archive of video]. From:

https://www.youtube.com/watch?v=PzV6coXvYsE