Q: What does the recent conviction of former nurse RaDonda Vaught teach us about medical errors and how to avoid them? 

A: In late March, RaDonda Vaught was convicted of gross neglect of an impaired adult and negligent homicide for administering incorrect medication, causing patient death. She was acquitted of reckless homicide. There is much to learn from the multiple factors that contributed to this tragedy. 

To mitigate medication errors, re-educate about the basics of medication administration. Nurses should use the “five rights” — the right patient, right drug, right dose, right route and right time — every time. Examine the process nurses use and audit to ensure compliance. For example, assess how staff identify the “right resident.” Do residents wear name bands? If not, how do staff ensure they have the right resident? 

Vaught overrode warnings within an electronic medication cabinet and indicated that overriding was a common practice. Research has shown nurses may experience alarm fatigue and become desensitized, leading to missed alarms or delayed responses. Remind staff to take every warning seriously and ask about ones they don’t understand. Audit on it.

Vaught also was training a nurse. Review your orientation process. Ensure that staff leading trainings have a lighter load to allow time for teaching.Verify those doing the training do so correctly. 

Vaught attributed the error to systemic failures in her hospital’s processes.

As nurse leaders, we must ensure our facilities’ systems promote safe care delivery. As nursing professionals, we also must work within those systems to provide appropriate care for the residents who depend on us.