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Root-Cause Analysis and Safety Improvement Plan
Introduction
In 2017, nurse Vaught fatally administered the wrong medication and caused a patients death. She was charged with reckless homicide and sparked debate over a recurring issue in medical practice. The discussion will focus on why this event occurred and provide evidence-based practices organizations can employ to prevent its occurrence. More importantly, organizations must train their staff and embrace a safety culture for policies to work.
Analysis of the Root Cause
The incident involved a former nurse, RaDonda Vaught, who worked at the Vanderbilt University Medical Center. In 2017, the nurse was assigned Charlene Murphey, a 75-year-old patient who was supposed to receive a sedative injection. Nurse Vaught mistakenly administered vecuronium, a paralyzing drug that eventually led to her patients death (Dolansky et al., 2022). Ms. Murphey needed a scan but was too nervous, encouraging her physician to order the sedative. Her death sparked outrage and support after nurse Vaught was charged with reckless homicide. The Centers for Medicare and Medicaid Services investigation found that a medical error caused Ms. Murpheys death (Dolansky et al., 2022). The event impacted Ms. Murphey, her family, civilians truth practitioners, and the entire healthcare industry. Many nurses argued in support of nurse Vaught due to the conditions under which they were forced to work. They noted that while the situation was inexcusable and heartbreaking, nurse Vaught represents every other healthcare practitioner susceptible to making mistakes.
However, investigations included arguments that showed the event could have been avoided. For instance, the medical error was caused by the lack of adherence to drug administration protocols. Nurse Vaught should have honored all the guidance that encompassed safe medication practices (Dolansky et al., 2022). For instance, the prosecution showed that the nurse did not find the sedative in the cabinet and ignored a safety standard (Dolansky et al., 2022). The American Nurses Association also argued that the event resulted from worker shortages and long hours (Dolansky et al., 2022). The organization posited that most nurses are subjected to immense fatigue, which challenges their ability to adhere to guidelines and safety practices (Dolansky et al., 2022). In addition, Leistikow (2018) argues that event was facilitated by the absence of tools to help nurses identify different types of medication and the minimum qualifications required to administer drugs due to shortages. All these factors emanate from the hospitals internal and external environment and are controllable.
The event may also have been triggered by the absence of technology tools to help the nurse locate the proper sedative. She failed to communicate this confusion to her superiors and acted on her own accord to select the first medication that appeared as VE in the search tool. The nurse had poor judgment and made a human error when she failed to ascertain that VE was the medication her patient needed (Dolansky et al., 2022). Hence, many argued that the nurse could have avoided this mistake if she had exercised her duty of care and communicated the confusion to the supervisor.
Evidence-Based Strategies
Literature suggests that simple actions help reduce medical errors significantly. For instance, Chapuis et al. (2019) argued that communication and double-checking have shown evidence of preventing errors during drug administration. For example, nurse Vaught may have prevented this mistake by checking the initials VE a second time to ensure she gave Ms. Murphey the proper medication. Chapuis et al. (2019) suggest that most practitioners fail to practice such safety standards due to minimal time and workload. However, double-checking lowers drug administration and prescription mistakes by close to 30% (Chapuis et al., 2019). A simple action within a nurses control can effectively prevent fatal errors.
Additionally, Chapuis et al. (2019) provide evidence that interprofessional communication and collaboration can reduce mistakes during drug administration. For instance, when nurses ask pharmacists about drugs whenever there is a misunderstanding, they significantly lower the chances of medical errors. A study by Leistikow (2018) also determined that labeling significantly affects medicines and prescriptions. Hospitals with properly labeled medicines reported fewer mistakes. Many used the full name of a drug or specific initials that make them unique and easily identifiable.
The strategies expressed in literature can be addressed in sentinel events by examining their causes and applying them to each case uniquely. While some events have similarities, others are caused by specific factors relating to practitioner behavior, standards of practice, or organizational culture. Therefore, the strategies can only be mitigated through individualized plans that address the issues causing the sentinel event. For example, a root cause analysis may indicate that an event was triggered by poor labeling and the lack of interprofessional collaboration within the organization. Hence, the evidence-based strategies reflected in the literature may be used to reduce these issues in the organization and prevent similar future cases.
Improvement Plan with Evidence-based and Best Practices Strategies
Vanderbilt University Medical Center needs to retrain all its nurses and practitioners directly involved in medicine administration. They need to understand the safeguards in place to prevent them from making medical errors and the consequences of bypassing any stipulated policies (Davis, 2022). Even though the hospital had a system where nurses could check the medication through initials, nurse Vaught ignored a standard that would ensure she double-checked the medicine and noticed the mistake. Hence, the situation indicates that the hospital has a tolerant attitude toward this behavior. The problem could also be explained by poor training that teaches nurses about the guidelines.
Hence, the nurses need to be retrained with an emphasis on medication policies and safeguards. They should learn to double-check medicines and use technology tools to reduce medication errors when administering drugs. The action seeks to reemphasize the importance of medication standards when administering drugs. Nurses must learn about the policies and why they were enacted to ensure they do not embody a culture that ignores these safeguards. The training will occur within six months since it must happen in waves and involve simulations and field experiments (Davis, 2022). Each group of nurses will be trained within a month and issued a test to determine their understanding of the safeguards and procedures needed for drug administration.
Existing Organizational Resources
The Vanderbilt University Medical Center has technological advancements and the tools to help nurses practice safe medication administration. For instance, the organization has a search tool where nurses could practice how to administer medication and countercheck whenever the details do not match or are confusing (Davis, 2022). Additionally, the technology can improve the simulation experience for the training and offer practical scenarios where nurses are placed in situations where they need to administer medication.
Conclusion
Errors during medication administration can be life-threatening, as established in nurse Vaughts case. Various evidence-based strategies are applied to make the process seamless and ensure patients use the proper medication. While some mistakes are unavoidable and subject to human imperfection, others are caused by a tolerant culture, poor safeguards, shortages, and the lack of qualifications from practitioners. Proper training and administration training are crucial to reducing this problem and enhancing patient safety.
References
Chapuis, C., Chanoine, S., Colombet, L., Calvino-Gunther, S., Tournegros, C., Terzi, N., Bedouch, P., & Schwebel, C. (2019). Interprofessional safety reporting and review of adverse events and medication errors in critical care. Therapeutics and Clinical Risk Management, 15, 549556. Web.
Davis, S. (2022). The lived experiences of educators involved in medical education simulation. International Journal of Healthcare Simulation. Web.
Dolansky, M. A., Barg-Walkow, L., Barnsteiner, J., McGaffigan, P., Oster, C. A., Schumann, M. J., Spencer, T., Chenot, T., Johnson, L. E., & Burke, K. G. (2022). A call to action following the RaDonda Vaught Case. Journal for Nurses in Professional Development, 38(6), 329332. Web.
Leistikow, I. (2018). Prevention is better than cure: Learning from adverse events in healthcare. Crc Press.
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