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Root cause analysis discovers the cause of problems by using a variety of approaches, tools, and techniques to uncover what lead to the problem. Root cause analysis also helps prevent reoccurring or alike problems and aids in decreasing the risk of high-risk situations.

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(Landman, 2022)

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1. Vanderbilt reported the accident under a natural cause of death.
2. Medicare/Medicaid investigated Vanderbilt and wanted to revoke funding due to fear of patient safety after an anonymous tip was given.
3. Vanderbilt put forward a plan of action of safety improvements.
4. Vanderbilt was in the middle of changing their medical record system which then caused the normal routine of overriding medications, meaning that overriding a medication would not have been abnormal.
5. The medication dispense system only went by generic name and not brand name. Versed needed to be searched using its generic name which is Midazolam, which RaDonda did not know and could not find on Charlene Murpheys chart.
6. After pulling the medication, while in the radiology department, RaDonda was not able to scan the medication to check the patient against the MAR and orders due to a scanner not being available.
7. During this time RaDonda was responsible for orienting a newly hired nurse, aid in the emergency department, and administer the medication to Charlene Murphey.
8. There were no other nurses available to aid in the emergency department due to inadequate staffing so RaDonda responded, while increasing her workload and teaching the newly hired nurse how to dispense medications.
9. Although Charlene Murphey should have been monitored after the medication was administered, RaDonda was told by the staff nurse as well as others that monitoring was not needed.
10. That day RaDonda was a "help all" nurse, in which she does not have patients of her own but is to assist across the hospital, meaning that she has little or fewer interactions with each patient and does not have much knowledge on that patient or their status.
(Williams et al., 2023)

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(The Chilling Effect of the RaDonda Vaught Prosecution, 2022)

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What are opportunities and/or plans of improvement to prevent similar situations in happen in the future?

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What are opportunities and/or plans of improvement to prevent similar situations in happen in the future?

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As healthcare workers our priority is patient safety. Reporting errors within the systems used daily and following the chain of command if the errors are not fixed would help prevent similar situations. The opportunity for improvement is here for not only Vanderbilt University but also for medical institutions nationwide as a mistake could happen to any front line nurse. I believe that nurse to patient ratio also has room for improvement, it is known that there is a nursing shortage, I hope that in the future facilities review how important adequate staffing is. I believe that there will be a need of improvement for nurses to report errors when they are made and the importance of reporting errors; I feel like the nursing community has now decreased doing this due to the RaDonda Vaught case. There is also an opportunity for Just Culture improvement, as Just Culture is defined as, " A system of shared accountability where organizations are held accountable for the systems they have designed as well as for responding to the behaviors of the organizations employees in a fair and just manner." (Lessons Learned from the RaDonda Vaught Ruling, 2023)

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There are many things that led to the distraction and administration of Vecuronium to Murphey. These include: 

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There are many things that led to the distraction and administration of Vecuronium to Murphey. These include: 

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Overring medication on a daily basis rather than in an emergency only situation. This was done routinely due to the machine often malfunctioning. After administering the wrong medication unknowingly, RaDonda was ordered by the staff nurse to not monitor the patient.  Due to inadequate staffing as well as orienting a new nurse, RanDonda was called from her main task to treat a patient in the emergency department when the call to administer the medication was made. RaDonda requested for the medication to sedate Murphey from a lab technician and not a clinician. There was no patient scanning device in the PET-scan room to aid in verifying patient drugs and patient drug doses. (Ramsay, 2022)

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How do we use root cause analysis in our facilities? 

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How do we use root cause analysis in our facilities? 

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The purpose of using root cause analysis in my facility is to help identify oversights, near misses, and problems that could potentially cause errors and in return, cause patient harm.

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It is our responsibility as nurses to always put patient safety first by using the skills taught and learned. RaDonda took all of the necessary measures after realizing her mistake. RaDonda reported her medication error to Vanderbilt in which Vanderbilt did not correctly report that Murpheys death, stating that she died of natural causes. It is the responsibility of the hospital to review problems with medication dispensing machines as well as correctly reporting the rightful cause of death of a patient. Instead, Vanderbilt did none of those things, chose not to fix their problems until after they were found falsely reporting misinformation about patient death, and decided to pin it on RaDonda Vaught.

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What were the major issues and contributing factors that led to the incident in the RaDonda Vaught Case? 

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What were the major issues and contributing factors that led to the incident in the RaDonda Vaught Case? 

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In December 2017 RaDonda Vaught made a fatal drug error, administering a fatal dose of vecuronium (a paralyzing medication) to 75-year-old Charlene Murphey, a patient at Vanderbilt University Medical Center who was recovering from a brain injury and was scheduled for a PET scan, resulting in her death. Murphey was prescribed Versed, a sedative which helps calm patients during PET scans that may struggle with claustrophobia. (Santa Clara University, 2022) RaDonda overrode the medication, something that RaDonda stated is done even when administering IV fluids and administered the vecuronium. After realizing her mistake, RaDonda made all of the correct steps and took all the correct necessary actions in reporting her error. In 2019 RaDonda was arrested and charged with reckless homicide as well as gross neglect of an impaired adult. (Kelman, 2022) Being found guilty and convicted of those charges on March 25th, 2022, having to serve three year’s probation and no jail time. (Adams, 2022)

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As a nurse, how does this affect how I provide care to my patients?

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As a nurse, how does this affect how I provide care to my patients?

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This case encourages me to always check my medications as taught, to always scan them, and to never override a medication unless in an emergent situation. As a nurse, you can never be too cautious when administering any medication to any patient.

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RaDonda Vaught apologizes to patients family.

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RaDonda Vaught apologizes to patients family.

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(Medina, 2022)

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Adams, M. T., Frank Gluck, Rachel Wegner, Molly Davis and Liam. (n.d.). RaDonda Vaught sentenced to three year’s probation on a diverted sentence, could see record wiped. The Tennessean. https://www.tennessean.com/story/news/crime/2022/05/13/radonda-vaught-sentenced-vanderbilt-nurse/9717529002/

Kelman, B. (2022, March 25). Former nurse found guilty in accidental injection death of 75-year-old patient. NPR. https://www.npr.org/sections/health-shots/2022/03/25/1088902487/former-nurse-found-guilty-in-accidental-injection-death-of-75-year-old-patient

Landman, K. (2022, May 13). A nurse was just sentenced to 3 years of probation for a lethal medical error. Vox. https://www.vox.com/science-and-health/2022/5/13/23066994/radonda-vaught-sentence-medication-error-patient-safety-lawsuit-vanderbilt-probation

Lessons Learned From the RaDonda Vaught Ruling. (n.d.). Outpatient Surgery Magazine. Retrieved September 25, 2023, from https://www.aorn.org/outpatient-surgery/article/lessons-learned-from-the-radonda-vaught-ruling#:~:text=A%20system%20of%20shared%20accountability

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Medina, E. (2022, May 15). Ex-Nurse Convicted in Fatal Medication Error Gets Probation. The New York Times. https://www.nytimes.com/2022/05/15/us/tennessee-nurse-sentencing.html

Opinion | The Chilling Effect of the RaDonda Vaught Prosecution. (2022, May 17). Www.medpagetoday.com. https://www.medpagetoday.com/opinion/second-opinions/98758

Ramsay, M. (2022, June 22). Lessons Learned From the RaDonda Vaught Case. Patient Safety & Quality Healthcare. https://www.psqh.com/analysis/lessons-learned-from-the-radonda-vaught-case/

University, S. C. (2022, June 1). Criminal Conviction of RaDonda Vaught sets Dangerous
Precedent in Reporting Medical Errors. Www.scu.edu. https://www.scu.edu/ethics/healthcare-ethics-blog/criminal-conviction-of-radonda-vaught-sets-dangerous-precedent-in-reporting-medical-errors/#:~:text=However%2C%20Vaught%20overrode%20the%20medical

Williams, K. N., Fausett, C. M., Lazzara, E. H., Bitan, Y., Andre, A., & Keebler, J. R. (2023). Investigative approaches: Lessons learned from the RaDonda Vaught case. Human Factors in Healthcare, 4, 100054. https://doi.org/10.1016/j.hfh.2023.100054

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What was this nurse charged with? Do you think this was fair after completing your research?

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What was this nurse charged with? Do you think this was fair after completing your research?

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RaDonda Vaught was charged with reckless homicide as well as gross neglect of an impaired adult. I do not feel like this charge was fair, as I think that RaDonda Vaught was used as a scape goat for Vanderbilt’s faults in their medical facility. We as nurses are humans and do make mistakes, unfortunately RaDondas mistake caused Murphey to lose her life but as nurses we know the consequences and importance of medication administration. On the other hand, due to to Vaught having many distractions and inadequate staffing, it can be every overwhelming and increase the room for error. I would like to believe that when administering a sedative, you would be more cautious and check your medications as you are taught to do. I have sympathy for RaDonda Vaught as well as contraindicating or conflicting beliefs pertaining to her case. I do feel that RaDonda Vaught should not have her license taken away from her forever.