How the RaDonda Vaught Case Could Impact Healthcare

Adverse medication events pose a significant risk to patients, healthcare staff, and the healthcare systems. However, focusing on medication administration processes and identifying potential risks can reduce the likelihood that medication errors occur.

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Adverse medication events pose a significant risk to patients, healthcare staff, and the healthcare systems. A former Nashville nurse, RaDonda Vaught, is facing up to eight years in prison after being convicted of negligent homicide and gross negligence of an impaired adult for inadvertently administering the wrong medication that killed an elderly patient at Vanderbilt University Medical Center in December 2017. This ruling has led to major discussions about organizational safety in the workplace, how the criminalization of medical errors could impact the healthcare system, and current medication safety policies.

Creating Organizational Safety

Professional nurses across the country have shared their fear of feeling forced to perform in unhealthy work environments which stem from staff shortages, mounting responsibilities, and continued pandemic response. So how can workplace culture shift so that healthcare professionals do not feel the need to take shortcuts on safety procedures? “Organizations should ensure that hard stops are in place to help prevent human errors and involve front line staff in developing processes that impact their workflow,” said Stacie Jenkins, Vice President of Patient Safety & Risk at LHA Trust Funds.

Creating and maintaining a safe and productive workplace for all employees is key to keeping everyone injury-free. Doing so will require continued assessment, plans of action, and employee education.

Creating a Non-Punitive Organizational Culture

It is unavoidable that human beings make mistakes – even those who service the healthcare industry. That is why administrators must create and maintain a culture that encourages the admission of errors without the fear of punishment or criminalization. A non-punitive corrective action to learn what occurred and work to prevent the same error is more advantageous.

Statements from national healthcare organizations such as the American Nurses Association (ANA) say that Vaught’s conviction could set a dangerous precedent having a “chilling effect” on incident reporting and process improvement. “Health care is highly complex and ever-changing, resulting in high risk and error-prone system. Organizational processes and structures must support a “just culture,” which recognizes that health care professionals can make mistakes and systems may fail. All nurses and other health care professionals must be treated fairly when errors occur. ANA supports a full and confidential peer-review process in which errors can be examined and system improvements and corrective action plans can be established. Swift and appropriate action should and must always be taken as the situation warrants.”

The ANA described the importance of transparent and just reporting mechanisms of medical errors that do not include the fear of criminalization. Nothing that these mechanisms preserve safe patient care environments.

“Targeting healthcare providers with the criminalization of medical errors only provides a path to an unsafe healthcare environment for providers and patients.” Said Dr. Dina Velocci, DNP, CRNA, APRN, president of the American Association of Nurse Anesthesiology (AANA).

Medication Safety Policies

Focusing on medication administration processes and identifying potential risks can reduce the likelihood that medication errors occur. Updating policies and guidelines, demonstrating safe practices, and conducting regular assessments are imperative to patent safety.

Providing employees with frequent medication safety education, with these combined tools, can also ensure safe medication practices and reduce the risk of adverse medication events.

Need More Resources?

LHA Trust Funds provides resources that can help reduce the risk of adverse drug events, help ensure the security of medications throughout the organization, and develop a workplace environment that promotes safety.

For an onsite assessment of your medication safety processes, please contact Stacie Jenkins at View our Medication Safety Toolkit and download the self-assessment resource to complete a quick assessment of your healthcare facility today.

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About the Author

Stacie Jenkins, RN, MSN, CPSO
Vice President of Patient Safety and Risk, LHA Trust Funds

Stacie Jenkins is a registered nurse with a master’s degree in nursing informatics. She has more than 20 years’ experience in healthcare, working in patient care and quality/performance improvement positions. As the Vice President of Patient Safety & Risk at LHA Trust Funds, she works closely with hospital administrators, risk managers and nursing staff to improve patient safety and establish best practices. She conducts on-site assessments and gives presentations designed to help clients address their patient safety risk management challenges.

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