When Medication Errors Are Fatal

• Mistakes happen all the time. No one is infallible against errors. Not even doctors or nurses, and especially not when it comes to medication administration. 
• Any medication given incorrectly by wrong drug, route, dosage, timing, or to the wrong client is considered a medication error. 
• Medication errors can be fatal, as seen in the news lately. It is up to our healthcare teams, administration, policies and processes to ensure the safety of our patients. 

 In the wake of the nursing shortage due to the COVID worldwide pandemic, exhausted nurses with inadequate personal protective equipment and working numerous overtime shifts, comes the release of a horrific story of a fatal medication error at the hands of a nurse.  

RaDonda Vaught, a 36-year-old critical care RN made a fatal medication error in 2017 when she administered vecuronium, a muscle relaxant that stopped her female patient Donna Murphy from breathing, instead of giving Versed, which is a sedative.  

Important factors that contributed to this event was that RaDonda was a float nurse for the entire hospital that was understaffed. The Pyxis machine was broken, and nurses had to hit override throughout the shift in order to obtain any medication. She was also orienting a new nurse in addition to working as a float to a unit she was not familiar with, and the patient was not on a cardiac monitor in the MRI machine.  

By the time the patient had a cardiac arrest, she identified the medication error and self-reported believing in the culture of safety for nurses and patients. Vanderbilt Hospital was found lacking in patient safety procedures and fined to make safety changes that were not followed.  

This is every nurse’s worst nightmare. There was no doubt it was a medication error and not intentional, however the outcome was the death of her 75-year-old patient and the resultant loss of her nursing license with a three-year probation for involuntary manslaughter.  

The additional serious implication is the fear nurses now feel about a threatened manslaughter sentence or any legal ramification for any medication error. That fear may prevent people from going into nursing or reporting a medication error.  

Convicting a nurse for a grave error threatens the morale of all nurses and patient safety by creating a culture of fear regarding medication administration.  Solutions need to be found that keep patients safe and nurses protected in a culture of support.  

What Are Medication Errors?

According to the National Coordinating Council for Medication Error Reporting and Prevention a medication error is defined as “any preventable event that may cause or lead to inappropriate medication use or patient harm while the medication is in the control of the healthcare professional, patient, or consumer.”  

Any medication given incorrectly by wrong drug, route, dosage, timing, or to the wrong client is considered a medication error. Many facilities now include a “near miss” event when the nurse almost had a medication error as a medication error itself and require the nurse to complete an incident report. It is left to the integrity of the nurse to record and respond to both a near miss and a real medication error.

Safe Medication Administration

Medication administration is a core nursing skill and task that requires training and knowledge to become a nurse. Because there are several steps and people involved in medication administration, a human error can occur at any stage.    

The process involves careful and appropriate selection of an FDA approved medication during the prescribing of a drug, correctly entering a drug into a computer system, review of the medication by a pharmacist, correct placement of a drug in a drug cart or electronic storage system such as a Pyxis for retrieval, which may be done by a pharmacist technician, focus by a nurse to recognize the correct medication and timing for administration of the drug in the electronic system, and correct preparation and dispensing of the medication to the right patient at the right time and right route.  

Nurses are trained to know the six rights of medication administration: right client, right dosage, right route, right time, right medication, and right documentation. They are also trained to check the medication three times: once when reading the medication order, second when retrieving the medication from a storage area, and third before the medication is given to the patient by checking for the six rights.  

There are a lot of steps in the process where errors can occur. Even a medication error that doesn’t cause an adverse effect to a client is considered a medication error.  

For example, if a client received two tablets of ibuprofen 325 mg oral instead of one tablet that was ordered, it is considered a medication error. Even if the patient received an increase relief of pain. Because it is a very human process, unfortunately errors can and do occur. When they are fatal it is devastating.  

The Facts on Medication Errors

Research reveals that up to 65% of nurses have made a medication error and another 31% reported a near miss event with medication administration and that human error increases under stress, anxiety, and additional hours worked.  

The most common errors were of dosage and IV infusion rate. Although an IV infusion rate error may sound mild, it is estimated that 251,000 deaths occur in hospitals where the majority of medication errors are caused by nurses and represents the third leading cause of death in America.  

Clearly the good-intentioned “angel of mercy” that nurses are often called, is not infallible if a nurse is not alert and attentive during medication administration.  

Although medication errors are frightening to nurses and patients, hospital administrators should look for ways to support nurses and not just seek punitive measures.

Supporting Nurses During Medication Errors

Some facilities have created physical alert methods such as electronic medical record alerting systems if a wrong medication is scanned. This is helpful if the nurse follows the policies. Errors increase when the nurse uses shortcuts to bypass the system.

Another strategy is putting a physical bright yellow tape on the floor around the medication cart which signals to others a do not detract zone to not bother the nurse during medication retrieval where a busy nurse may be doing medication calculations before giving a medication.  

Hospitals and facilities have also created systems to support the nurse in reporting sound-alike-look-alike medications and flagging them to alert the nurses who give the medication. Tags written SALAD (sound alike, look alike drug) have even been put on bottles and medication packaging. These systems only work however, if the nurse follows the prompts and isn’t distracted.  

The biggest strategy proposed by nurses is to support them with adequate staffing and lower nurse to patient ratios to decrease the stress and workload of the nurses. Unfortunately, it always comes down to cost. Most facilities struggle to hire sufficient nurses when reimbursement of patient expenses is so low by insurance companies. Profits are squeezed. Like dominos set up in an intricate pattern, which can tumble when just one piece falls, it is a complex problem.  

Ultimately the best control each nurse has is to approach medication administration with full focus, every time. Nurses can advocate for each other and treat medication administration as a protected and “almost sacred” activity and not bother or disrupt each other when giving medications.   

Policy Implementation to Prevent Medication Errors

Because the initial step in drug administration begins with FDA approval, the FDA keeps record of all adverse drug effects and receives up to 100,000 reports of suspected medication errors annually. Suspected medication errors and adverse effects are reported by drug manufacturers and healthcare professionals, and consumers through the MedWatch system.  

Nurses can contribute by recording medications that are problematic for administration such as confusing labeling or sound alike names. If a nurse has made a mediation error, they need additional support and education by their facility. If, however, a nurse is impaired or negligent, that is another story.  

Safe staffing ratios is essential, and nurses can voice this as a foundational right in our work role. Perhaps, using the phrase “Murphy’s Check” can begin a cultural and legal movement towards improved patient safety. 

The Bottom Line

No nurse wants to make a medication error. No nurse wants the fear of going to jail because of a medication error. Nurses do need to be held accountable for their errors, but not to be thrown in jail.  

Healthcare truly is a team sport and working together for the safety of our clients requires collaboration and not punitive measures. Looking for more effective systems and protective processes together is needed. If nurses need more staff, more education about medications, more time off from shifts worked in a row, and quiet during medication administration, those deserve our attention.  

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