Presenter Information

Venisa Morgan
Janice Miles

Location

Virtual Conference

Start Date

24-6-2022 1:30 PM

End Date

27-6-2022 2:10 PM

Description

Background: Former Vanderbilt University Medical Center nurse, RaDonda Vought, was charged with criminally negligent homicide in March 2022 for a fatal drug error. Ms. Vought’s license was revoked and she was sentenced to three years of probation.

Purpose/aim: This poster presentation aims to inform attendants of the ethical principles involved in medication administration error reporting and the concepts of a Just Culture. This poster also aims to inform attendants of the American Nurses Association’s (ANA’s) and National League for Nursing’s (NLN’s) perspectives on the RaDonda Vought case, outcomes, error reporting, and Just Culture.

Methods/Approach: A search was completed for the ANA’s and NLN’s perspectives and/or position statements on the RaDonda Vought case and outcomes. Information was retrieved from current resources regarding the Vought criminal case, ethical principles, Just Culture, and the ANA and NLN perspectives.

Results: Nursing workplaces are fast-paced, high-stakes environments. Nursing workplace environments often encounter staffing shortages, have varying patient acuity, and pose risks for work-related injury or illness. The ethical principles of nonmaleficence, veracity, and justice apply to the reporting of medication administration errors and to the RaDonda Vought case. The ANA and NLN support a Just Culture workplace environment where nurses and health care professionals are able to safely report medical errors so to improve processes that promote safety. The ANA recognizes that systems can contribute to medical errors and that individuals should not be penalized for errors in which the system was at the root cause. The NLN warns there is danger in criminalizing health care errors and the ANA concurs that this would not preserve safe patient care environments.

Conclusion: Medication administration errors are a serious patient safety issue which can also include severe consequences for the nurse. The RaDonda Vought criminal case has seemingly raised the stakes of medication administration errors and medical error reporting. The outcomes of the trial and its place within a Just Culture workplace environment should be considered with respect to the ANA and NLN perspectives.

Implications for Practice: The RaDonda Vought case may have set a dangerous prescient for medication errors, error reporting, and nursing implications for medical errors. Nurses should practice medication administration with vigilance and regard to the ethical principle of nonmaleficence. Attention should be brought to workplace systems and processes that increase risk for medical errors. A Just Culture workplace is supported by the ANA and NLN for medical errors and medical error reporting.

Share

COinS
 
Jun 24th, 1:30 PM Jun 27th, 2:10 PM

Medication Administration Error Reporting and Just Culture: ANA and NLN Perspectives

Virtual Conference

Background: Former Vanderbilt University Medical Center nurse, RaDonda Vought, was charged with criminally negligent homicide in March 2022 for a fatal drug error. Ms. Vought’s license was revoked and she was sentenced to three years of probation.

Purpose/aim: This poster presentation aims to inform attendants of the ethical principles involved in medication administration error reporting and the concepts of a Just Culture. This poster also aims to inform attendants of the American Nurses Association’s (ANA’s) and National League for Nursing’s (NLN’s) perspectives on the RaDonda Vought case, outcomes, error reporting, and Just Culture.

Methods/Approach: A search was completed for the ANA’s and NLN’s perspectives and/or position statements on the RaDonda Vought case and outcomes. Information was retrieved from current resources regarding the Vought criminal case, ethical principles, Just Culture, and the ANA and NLN perspectives.

Results: Nursing workplaces are fast-paced, high-stakes environments. Nursing workplace environments often encounter staffing shortages, have varying patient acuity, and pose risks for work-related injury or illness. The ethical principles of nonmaleficence, veracity, and justice apply to the reporting of medication administration errors and to the RaDonda Vought case. The ANA and NLN support a Just Culture workplace environment where nurses and health care professionals are able to safely report medical errors so to improve processes that promote safety. The ANA recognizes that systems can contribute to medical errors and that individuals should not be penalized for errors in which the system was at the root cause. The NLN warns there is danger in criminalizing health care errors and the ANA concurs that this would not preserve safe patient care environments.

Conclusion: Medication administration errors are a serious patient safety issue which can also include severe consequences for the nurse. The RaDonda Vought criminal case has seemingly raised the stakes of medication administration errors and medical error reporting. The outcomes of the trial and its place within a Just Culture workplace environment should be considered with respect to the ANA and NLN perspectives.

Implications for Practice: The RaDonda Vought case may have set a dangerous prescient for medication errors, error reporting, and nursing implications for medical errors. Nurses should practice medication administration with vigilance and regard to the ethical principle of nonmaleficence. Attention should be brought to workplace systems and processes that increase risk for medical errors. A Just Culture workplace is supported by the ANA and NLN for medical errors and medical error reporting.