Expert on Nurse Medication Errors Places Vaught Case in Context

In May 2022, former nurse RaDonda Vaught was sentenced to three years’ probation for a fatal medication error, an unprecedented criminal conviction that echoed through the nursing community, and the implications of which are still to be fully determined. In an interview, Zane Robinson Wolf, PhD, RN, CNE, ANEF, FAAN, who has studied patient safety and medication errors for decades, expressed concern that this may have a chilling effect on reporting medication errors and thus harming patient safety.

Deep expertise

Wolf, the editor-in-chief of the International Journal for Human Caring, is dean emerita and professor of nursing at the School of Nursing and Health Sciences at La Salle University, Philadelphia, PA. She has been researching issues around patient safety since her 1986 dissertation “Nursing rituals in an adult acute care hospital: An ethnography.”

She directly observed nurses preparing and administering medications, and nurses began to tell her their medication error stories. Wolf was a member of the board of the Institute for Safe Medication Practices (ISMP), a highly respected organization that distributed alerts, information and analysis about medication errors. In 2020, ISMP affiliated with ECRI to create one of the largest healthcare quality and safety entities in the world.

Three phases

Wolf says she has lived through three phases or ways of thinking about medication and other healthcare errors. In the first phase, perfectionism, “providers are supposed to be perfect, but since we’re human, we’re not,” she says. In this “blame the provider” phase, the clinician was often blamed for the error.

Understanding context

In analyzing the Vaught error, Wolf points to the importance of the error’s context. Vaught admitted to investigators that she had been “distracted with something,” according to a New York Times report. Vaught administered the neuromuscular blocking agent vecuronium instead of the sedative Versed.

The ISMP, commenting on the case in a press release, noted that the trial ignored existing science about confirmation bias, inattentional blindness, alert fatigue, and normalization of automated dispensing cabinet overrides.

“The context is important in terms of the patient load she was carrying at the time,” notes Wolf. “How many patients were basically under her care at that point?”

In committing the error, Vaught was said to have overridden a system when she couldn’t find Versed, typed in “VE,” and chose the first medication on the list, vecuronium, notes the Times quoting a Tennessee Bureau of Investigations report. Wolf says that confirmation bias could have played a role, where Vaught read the VE for what she was expecting, Versed, instead of the actual drug she selected, vecuronium.

The ISMP, commenting on the case in a press release, noted that the trial ignored existing science about confirmation bias, inattentional blindness, alert fatigue, and normalization of automated dispensing cabinet overrides. If healthcare providers fear harsh penalties such as imprisonment, they’ll be less likely to disclose errors or be willing to describe workarounds that set them up to make errors, the ISMP notes.

Quadruple Aim

In helping healthcare providers cope with medication errors, as well as other traumatic events, Wolf points to the Quadruple Aim. Building on the Triple Aim of the Institute for Healthcare Improvement, the Quadruple aim adds the idea that providers should work in a supportive workplace, notes Wolf.

Wolf points to a report of a support structure for the “second victims” of adverse clinical events. This structure was designed to increase awareness of the second-victim phenomenon, normalize psychological and physical impacts, provide real-time surveillance for potential second victims in clinical settings, and provide immediate peer-to-peer emotional support.

A mistake versus a crime

According to Wolf, Vaught “did violate safety, but I think the intentionality is not there. And that to me is what breaks down the difference between a crime and a mistake. And it is a glaring mistake. There is no doubt about it. But it’s very alarming to all kinds of healthcare providers, not just nurses, but anybody who’s administering a medication.”

“I think the intentionality is not there. And that to me is what breaks down the difference between a crime and a mistake. And it is a glaring mistake.”

“I think that people need to know that as healthcare providers care for patients, their actions have high consequences with important impacts for patients,” says Wolf. “And that safety is a persistent concern of providers and leaders of healthcare systems. This work of caring is a weighty responsibility. But if we want to do this activity in life, we live with it and go forward. It’s a choice. But reporting near misses and errors is always the best avenue and we should never be dissuaded from that.”