The Incident Telephone interview with RoDonda Vaught on 11/5/18…
Question The Incident Telephone interview with RoDonda Vaught on 11/5/18… The Incident Telephone interview with RoDonda Vaught on 11/5/18 beginning at 4:41 PM, RoDonda was asked to describe the circumstances leading up to the Patient’s death on Tuesday 12/26/17. RoDonda stated, “I was in a patient care role, I was the “help-all nurse”. A help-all nurse is a resource nurse and I had an Orientee… The primary nurse asked me to go downstairs to PET scan and give the patient Versed because [the patient] was not able to tolerate it [the PET scan procedure] or they would have to send her back and reschedule it. We were already heading to ER to do swallow study on a patient. I went and searched for the med under [the patient’s] profile [in the ADC (automated drug cabinet)] and it was not there. I chose the override setting and I searched for it. I was talking to the Orientee about why we do swallow studies in the ER…I typed in the first 2 letters [VE] and that’s how I hit it, I chose the 1st one on the list. I took out the vial and I looked at the back at the directions for how much to reconstitute it with, I did not re-check the name on the vial… I saw 1 patient on one of our beds, I checked the patient for her identity, and told [the patient] I was there to give her something to help her relax… I reconstituted it and measured the amount I needed… One of the Radiology Technicians came out, I gave the med, flushed it and we left. The Radiology Technician took the patient back. We went straight to the ER from there… I am not sure if I drew up and gave him/her what she needed… heard a rapid response call for PET scan. That was a red flag since out patient was ours… we were being responsible to go to see if it was our patient… when we got there they had intubated her and got a pulse back. The Physician, Charge Nurse, myself and the team, we collectively moved her bed back to the unit. I told the Physician that I had given [the patient] Versed a few minutes ago…I reminded the Nurse Practitioner that the Patient was awake but unmonitored when I gave her the Versed. We spent probably about 45 minutes getting labs and things. I had drawn several tubes of blood for labs when another RN came up to me and she said, “Is this the med you gave her?” I said yes, we need to waste it. The RN stated, “This isn’t Versed” I said what is it? she said, “It’s Vecuronium” and I went back into the patient’s room and the Physician, a couple of residents, and the Nurse Practitioner were in the room discussing what was happening. I told them right then it was my mistake. I told them I gave Vecuronium. They all knew it right then. The Nurse Practitioner said, “I’m so sorry” and I left the room. I am not sure where I went but I ended up in the educator’s office. I spoke to management – different people. I filled out the “Veritas” [Hospital’s reporting system]. This was around four-ish [4:00 PM]. I gave both my phones to the charge nurse and the Orientee was assigned to someone else. It was after 8:00 PM when I left.” RoDonda was asked if she documented the Vecuronium in the Patient’s medical record. RoDonda stated, “I did not. I spoke with my Nurse Manager and she told me the new system would capture it on the MAR [Medication Administration Record]. RoDonda stated that she left the Patient in Radiology. RoDonda confirmed that she did not monitor the Patient after the medication was administered (CMS, 2018, p. 23-26). ReferencesCenters For Medicare & Medicaid Services (CMS). (2018). Statement Of Deficiencies And Plan Of Correction. NPR Choice page. (2019). Npr.Org. https://www.npr.org/sections/health-shots/2019/04/10/709971677/when-a-nurse-is-prosecuted-for-a-fatal-medical-mistake-does-it-make-medicine-safQuestions 1. Please identify at least 5 errors RaDonda made when administrating medication. 2. Identify anyone else who could be at fault in this case and state why. 3. Do you think it was her responsibility to monitor the patient after giving the medication? Explain your answer. 4. Do you think RaDonda took the correct action once the medication error was identified? Please explain your answer. 5. Do you think the hospital took the correct action after the medication error was identified? Please explain your answer. 6. Do you think a nurse should be criminally liable for a medication error? Please explain your answer. 7. How does this change your feelings on passing medications to patients? 8. Do you think medication errors are 100% preventable? Why? 9. What should a nurse do to help prevent medication errors? Health Science Science Nursing COMT MISC Share QuestionEmailCopy link Comments (0)
