[From 10$/Pg] Normal Operating Procedure Used

[From 10$/Pg] Normal Operating Procedure Used

find a recent medical error that made the news. 

  1. What happened in the incident?
  2. Who was involved?
  3. What were the ramifications for the patient and/or staff?
  4. Reflect on the incident and think about some causes and possible interventions that could have prevented the error.

then reply to Pat

1. What happened in the incident that I am speaking about truly made large waves through the nursing community. The nursing community as a whole has been challenged, sharpened, and even divided. My topic is about nurse RaDonda Vaught. This nurse worked in Tennessee at one of the most well known and trusted nursing institutions, Vanderbilt University hospital. This is where a medical error on the part of a nurse cost the life of a patient. The wrong medication was given and it had deadly consequences.

2. Who all was involved? in this specific situation, there are only a few people directly involved with the medical errors but there are now many individuals involved in the case overall. The overall involvement of different entities has just exploded in this case. The board of nursing has held official hearings in regard to what happened on that fateful day. The families of both of the involved individuals have been affected greatly by the actions on that day.

3. The ramifications have been numerous for those involved. The nurse has been criminally prosecuted and went before a court hearing. This is explained further, “in Nashville on criminal charges of reckless homicide and felony abuse of an impaired adult for the killing of Charlene Murphey, the 75-year-old patient who died at Vanderbilt University Medical Center in late December 2017. If convicted of reckless homicide, Vaught faces up to 12 years in prison (Kelman, 2022)”. There has also been a number of things that have come up in the charge. “The DA’s office points to this override as central to Vaught’s reckless homicide charge. Vaught acknowledges she performed an override on the cabinet. But she and others say overrides are a normal operating procedure used daily at hospitals (Kelman. 2022)”.  There has been much backlash on the hospital for allowing such an override to happen. This was a normal process that the hospital allowed to happen. This has caused outrage and adjustments to the system.

4. When thinking about the best way to look at this, I think there are many different ways. First, I do not believe that there is any doubt that the nurse is in the wrong for not being more diligent as a nurse. There are practices that you learn all the way in nursing school that could have helped her avoid this tragic action. If there were more checks concerning the pulling of paralytic agents, there would have been a chance for someone else to catch the error. This would have been good, because the nurse obviously wasn’t in the frame of mind to make logical decisions even if there were other steps she had take.



Kelman, B. (2022, March 22). As a nurse faces prison for a deadly error, her colleagues worry: Could I be next? NPR. Retrieved January 30, 2023, from https://www.npr.org/sections/health-shots/2022/03/22/1087903348/as-a-nurse-faces-prison-for-a-deadly-error-her-colleagues-worry-could-i-be-next