1 Written Assignment: Medication Error Analysis in the Geriatric Patient Joann Jeannot Barbara H. Hagan School of Nursing and Health Sciences: Molloy College NUR 2390 01: Human Growth and Development across the Lifespan Dr. Andrea Spatarella November 15th, 2021 2 As healthcare providers, nurses have a great deal of responsibility that weighs on their shoulders – they have a duty to not just their patients, but their patients’ family members and other healthcare providers as well. One of those major responsibilities that they are tasked with is the safe administration of medication to patients. It is important to emphasize that nurses are the last line of defense between the medications and the patients themselves. This is particularly important with patients who are in a clinical setting such as a hospital, as the prescribed medication will not be administered until the nurse gets a hold of it. Once a provider orders and prescribes a medication for a patient, what happens afterwards is completely out of their scope of practice, although this may depend on the state laws in which the provider practices in. As student nurses in an undergraduate nursing program, one of the required courses that must be taken is Pharmacology, a course in which we not only learn about various medications – including their uses and methods of action, but also the proper administration of some of these medications. In addition to learning about different types of medications, one important concept that is emphasized and stressed frequently in Pharmacology would be the Five Plus Five Rights of Drug Administration, which includes: right patient, right drug, right dose, right time, and right route. Some further responsibilities for the nurse to adhere to or consider when preparing to administer medications would include the right assessment, right documentation, patient’s right to education, right evaluation, and patient’s right to refuse. Each of these components of the Five Rights are essential for nurses to follow as any misstep, hindrance, or deviation from just one of them along the way may result in dire consequences, such as serious injury or even death to a patient. In fact, as Abrahamson and Anderson (2017) highlight, medication errors are the third leading cause of death in the U.S., accounting for about 251,000 deaths annually. 3 One such case of patient death due to a medication error involved a nurse who injected a patient with a paralytic medication called Vecuronium instead of the intended medication, a sedative called Versed. RaDonda Vaught, a 35-year-old nurse who worked for Vanderbilt University Medical Center in Nashville, Tennessee was charged with reckless homicide after a December 2017 medication error resulted in the death of a 75-year-old patient named Charlene Murphey. Murphey, a patient diagnosed with a cerebral hematoma who was scheduled to undergo a PT scan, was prescribed 2 mg of Versed (midazolam hydrochloride) to treat her anxiety related to the procedure (Loller, 2019; Peeples, 2019). Versed, which induces preoperative sedation or amnesia and controls preoperative anxiety, results in a calming effect that relaxes the skeletal muscles in patients and may in some cases induce sleep with a higher dosage (Jones and Bartlett, 2015). Vaught looked for the medication in a nearby electronic medication cabinet but was unable to find the drug in the patient’s profile. This was because she was searching for the prescribed drug by its brand name when the machine was programmed to find drugs by their generic names (Leone, 2021). When she couldn’t find the Versed, Vaught then proceeded to activate the override function of the medication cabinet by entering the letters “VE” into the search field, and then without thinking, grabbed the first drug that appeared with those two letters, which was the drug Vecuronium bromide (Institute for Safe Medication Practices, 2019). This drug helps the skeletal muscles relax during surgical operations or mechanical ventilations, but the unintended use of it can result in paralysis, ultimately leading to respiratory arrest and death, which is what unfortunately occurred with Mrs. Murphey (Food and Drug Administration, 2018). While some may view Vaught’s error as minor, her actions and clinical judgement were grossly negligent. Vaught even admitted to investigators that she was distracted while speaking 4 with a new employee while this incident took place. There were also many red flags throughout the process of 1) finding the medication 2) preparing the medication for use and 3) administering the medication itself that led to this horrific situation transpiring. One red flag that Vaught should’ve caught or noticed while preparing the medication, which is something that the prosecution emphasized, was that the vial bottle for the Vecronium Bromide medication is red with a cap that reads in plain bold letters: “WARNING: PARALYZING AGENT” (Cooke, 2019; Morris, 2021). If she had paid attention to what medication she was preparing to give her patient instead of directing her attention elsewhere, she would’ve noticed the clear warning in boldfaced letters for this high alert medication. Another red flag would be the fact that she didn’t scan the medication to put into the patient’s electronic medical record (EMR). If she did, the error would have appeared in the computer system, and she would’ve noticed it. Other red flags along the way include the fact that the Vecronium Bromide appeared in the computer system multiple times with the words “PARALYZING AGENT” in bold letters, which Vaught failed to notice, the fact that Vaught didn’t realize that the intended medication Versed comes in liquid form instead of powder form like the drug actually given, and the fact that Vaught would have needed to reconstitute and shack the bottle of the medication she picked up, which isn’t required for Versed. Ultimately, the death of Mrs. Murphy lies solely with Vaught, as she didn’t follow the standard protocols indicated in the nursing scope of practice regarding medication administration (Shelton, 2019). The error occurred because instead of paying attention and attending to her designated task – a very important task at that, Vaught allowed herself to be distracted by a conversation with a new employee. It didn’t have to get this far if Vaught took this task seriously by going through the 5 Rights of Medication Administration, which would’ve caught the error early on. This error could’ve been prevented even earlier if Vaught had used her clinical 5 judgement when she couldn’t find the Versed in the medication cabinet. She could’ve consulted with another nurse for assistance in what to do in this situation, or she could’ve called the pharmacy to confirm the order for clarity. This wasn’t an emergency, so Vaught could’ve taken her time trying to find the medication instead of cutting corners by overriding the electronic medication system. Sadly, an innocent life that will never return was lost due to these actions. Like other healthcare professionals, nurses are human, and as such will make mistakes. That is why it is extremely important that they be very cautious and on high alert when administering medications, especially high alert medications that can pose severe harm to patients. Vaught’s case serves as an unfortunate, but valuable teaching moment for all nursing students, as it serves as a prime example of what actions nurses shouldn’t commit when dealing with such high alert medications. Her case also emphasizes how important it is to fully follow all standard protocols and procedures when it comes to nursing duties and responsibilities such as medication administration. Allowing distractions and cutting corners is dangerous and can potentially cause patients serious harm, or even death. Nurses can and will make mistakes, but there are many things that can be done to reduce the number of instances of these mistakes, which will ultimately improve patient safety long-term. 6 References Anderson, J. G., & Abrahamson, K. (2017). Your Health Care May Kill You: Medical Errors. Studies in health technology and informatics, 234, 13–17. Cooke, K. (2021, July 26). Prosecutors: Former Vanderbilt Nurse missed multiple warnings before giving Patient Deadly Drug. WSMV Nashville. Retrieved October 24, 2021, from https://www.wsmv.com/news/prosecutors-former-vanderbilt-nurse-missed-multiplewarnings-before-giving-patient-deadly-drug/article_debe8484-50e1-11e9-974b675e3734a057.html. Food and Drug Administration. (2018, July). Vecuronium bromide for injection. Retrieved October 23, 2021, from https://www.accessdata.fda.gov/drugsatfda_docs/label/2018/075549s013lbl.pdf. Institute For Safe Medication Practices. (2019, February 14). Another round of the blame game: A paralyzing criminal indictment that recklessly "overrides" just culture. Institute For Safe Medication Practices. Retrieved October 24, 2021, from https://www.ismp.org/resources/another-round-blame-game-paralyzing-criminalindictment-recklessly-overrides-just-culture. Jones & Bartlett Learning. (2015). 2015 Nurse's Drug Handbook (14th ed.). Leone, J. (2021, July 26). Nurse who killed patient with Wrong Medicine Loses Nursing License. WHIO TV 7 and WHIO Radio. Retrieved October 24, 2021, from https://www.whio.com/news/trending/nurse-who-killed-patient-with-wrong-medicineloses-nursing-license/BLZ7MYEL45GBJC2UFLM3DL746U/. 7 Loller, T. (2019, February 20). Nurse charged in fatal drug-swap error pleads not guilty. AP NEWS. Retrieved October 24, 2021, from https://apnews.com/article/health-tennessee-usnews-nashville-homicide-bbc0c863fba146658786e4b91cb5dbc4. Morris, C. (2021, May 28). Trial date set for former Vanderbilt nurse accused of giving fatal dose of wrong medicine to patient. WSMV Nashville. Retrieved October 24, 2021, from https://www.wsmv.com/news/davidson_county/trial-date-set-for-former-vanderbilt-nurseaccused-of-giving-fatal-dose-of-wrong-medicine/article_700e1322-bf09-11eb-b1f36f239020a767.html. Peeples, L. (2019, January 8). Pharmacypracticenews.com. Retrieved October 24, 2021, from https://www.pharmacypracticenews.com/Clinical/Article/01-19/Another-FatalVecuronium-Error/53755?enl=true&sub=F09D4E1AEB1935236B7DD88EBF3511796624DD9967A417E04 A63FAD9FB86. Shelton, C. (2019, March 28). Investigation: Former vandy nurse admits she 'f----D' up, multiple overrides lead to death. WZTV. Retrieved November 11, 2021, from https://fox17.com/news/local/investigation-former-vandy-nurse-admits-she-f-d-upmultiple-overrides-lead-to-death.