Week 4

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School

Jomo Kenyatta University of Agriculture and Technology *

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Course

C2346

Subject

Nursing

Date

Nov 24, 2024

Type

docx

Pages

Uploaded by SargentBookSquirrel5

A nurse named RaDonda Vaught was involved in a fatal medication error that occurred in late December 2017 at Vanderbilt University Medical Center in Nashville, Tennessee. The incident led to the death of Charlene Murphey, a 75-year-old patient who was admitted to the hospital for a brain injury. What happened in the incident: Charlene Murphey was prescribed a sedative called Versed to calm her before undergoing a medical scan. RaDonda Vaught, the nurse responsible for administering the medication, mistakenly retrieved a powerful paralyzer called vecuronium from a computerized medication cabinet instead of Versed. Several warning signs were overlooked during the medication retrieval process, including the fact that Versed is a liquid while vecuronium is a powder. Vaught administered the wrong drug to Murphey and left her to be scanned. By the time the error was discovered, Charlene Murphey was brain-dead, and she ultimately died as a result of the medication error. The individuals involved: RaDonda Vaught: The nurse responsible for administering the medication. Charlene Murphey: The patient who received the wrong medication and tragically died as a result. The ramifications

Charlene Murphey lost her life due to a medication error, which had a devastating impact on her and her family. RaDonda Vaught faced criminal prosecution and was convicted of gross neglect of an impaired adult and negligent homicide. She potentially faces a prison sentence of three to six years for neglect and one to two years for negligent homicide. The incident received national attention and was closely followed by nurses and medical professionals across the country, leading to concerns that it could set a precedent for criminalizing medical mistakes. Some individuals within the nursing community worried that the conviction could deter nurses from disclosing their own errors or near-errors, potentially impacting the quality of patient care. Interventions that could have prevented the error: I. Ensuring that strict medication safety protocols are in place and followed rigorously to prevent medication errors (Samaranayake et al, 2013). This includes verifying the medication with multiple checks, including the medication's name, dosage, and form. II. Providing comprehensive training and ongoing education for healthcare professionals, emphasizing the importance of attention to detail and vigilance when administering medications. III. Addressing any systemic problems related to medication cabinets or medication delivery systems in healthcare facilities to minimize the risk of errors. IV. Encouraging a culture of reporting and accountability in healthcare organizations, where healthcare professionals feel comfortable reporting errors or near-misses without fear of punitive actions.

V. Implementing a system of double-checks for high-risk medications, especially when there are multiple medications with similar names or appearances. VI. Utilizing technology solutions such as barcode scanning and electronic medication administration records (eMAR) to reduce the risk of medication errors. References Kelman, B. (2022, March 22). As a nurse faces prison for a deadly error, her colleagues worry: Could I be next? NPR . https://www.npr.org/sections/health- shots/2022/03/22/1087903348/as-a-nurse-faces-prison-for-a-deadly-error-her-colleagues- worry-could-i-be-next Samaranayake, N. R., Cheung, S. T. D., Chui, W. C. M., & Cheung, B. M. Y. (2013). The pattern of the discovery of medication errors in a tertiary hospital in Hong Kong. International Journal of Clinical Pharmacy , 35 (3), 432–438. https://doi.org/10.1007/s11096-013-9757- 0

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