There likely isn’t a single clinician who hasn’t thought about the RaDonda Vaught case at least once in recent months — especially nurses. The circumstances involving a lethal medication error revealed glaring flaws in an already fractured and strained health care system, and her sentence of probation left many wondering if they would be next.
In 2017, Vaught administered vecuronium instead of Versed, leading to the death of her patient. Are errors like this intentional harm? How can we learn from her mistake so that it never happens again? Doximity polled 277 NPs and CRNAs on how medication errors can best be prevented. Nearly half (43%) of respondents believe that medication dispensing systems should be better designed for real-world practice. Over a third (33%) think the solution lies in cultivating a culture of trust and safety for error reporting. Thirteen percent believe that there should be more stringent safety checks and protocols in place to protect both patients and clinicians. And 10% of respondents think that either a combination of these solutions or something else entirely would prevent medication errors.
Many of the respondents raised issues surrounding automated medication dispensing systems. During RaDonda Vaught’s trial, Ethan Gulley, a former Vanderbilt nurse testified that “nurses were experiencing delays at medication cabinets,” and “nurses could use overrides to overcome these delays.” If nurses receive the green light to override warnings, do they become immune to critical warning messages? Deana Andrews, a family NP, suggested, “Decrease alarm fatigue. We are all so burned out with constant pop-ups and alarms that we tend to mindlessly click through them.”
NPs offered their own solutions for overcoming the potential dangers of alarm and notification fatigue. Sopa Mahaboonpachai, NP, suggested, “Designation of one medication dispensing machine for high risk medications separate from [one] with common medications. List generic and brand name drugs with indication for each drug.” Several other nurses also suggested listing medications by their generic names. One anesthesiology NP further added, “Mandate use of generic names and require [a set amount] of letters be typed in as a unique identifier for that institution’s formulary.” Several NPs who responded to the poll commented on nurse-to-patient ratios as an additional factor in medication errors. Kelly Bouthillet, NP, shared that “better [medication administration] workflows can result from nursing driving solutions, as well as safe staffing.” Deneen Norman, NP, suggested that “a nurse shouldn’t care for more than four of five patients on the floors.”
Adequate staffing equals patient safety, as various studies have shown. A JAMA study found that the likelihood of patient mortality increased by 7% for each additional patient added to a nurse’s workload. Additionally, this study found that hospitals staffing one nurse to eight patients experience five additional deaths per 1,000 patients, compared with hospitals that staff one nurse to four patients.
Many NPs and CRNAs agree that there needs to be changes in the way health care systems and clinicians deliver medications to patients. According to a 2021 study, “in the United States alone, 7,000 to 9,000 people die as a result of a medication error. Additionally, hundreds of thousands of other patients experience but often do not report an adverse reaction or other medication complications. The total cost of looking after patients with medication-associated errors exceeds $40 billion each year.” RaDonda Vaught’s lethal medication error was one of thousands that occur every year in the United States. As Paige Clifton, NP, noted, “Don’t make a single nurse a scapegoat for a systems problem.”
How are you and your workplace preventing medical errors on a systems level?
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