Complete a Root Cause Analysis based on this case:
1.
1. Explain what a Root Cause Analysis is and the purpose of using one for your facility.
2. What were the major issues and contributing factors that led to the incident in the RaDonda Vaught Case? What occurred based on facts shared in these resources?
1. Please include all details surrounding this case. Explain the situation and causes. Speak to issues that may have led to distraction, protection of the hospital, nursing responsibilities, and anything else you feel is pertinent to share about this case.
3. What, how, and why did this incident occur?
4. What was this nurse charged with? Do you think this was fair after completing your research?
5. What are opportunities and/or plans of improvement to prevent similar situations in happen in the future? Identify the best evidence(s) to support policy development related to this issue.
6. Please also share your feelings and concerns as a result of studying this particular case. How can you better protect your patients and yourself?
7. Create a safe medication administration flyer or announcement to display in your facility. Please include a picture of your flyer or announcement to include in this presentation.
. Major Issues and Contributing Factors in the RaDonda Vaught Case
The RaDonda Vaught case involves a former Vanderbilt University Medical Center (VUMC) nurse who mistakenly administered a paralyzing agent, vecuronium, instead of the sedative Versed (midazolam), leading to the death of patient Charlene Murphey in December 2017.
Incident Details and Contributing Factors:
| Category | Contributing Factors (Systemic Failures) | Nurse Vaught's Direct Errors |
| Technology/System Design | 1. System Override Required (The "Wasting" Failure): The intended medication, Versed, was not stocked in the unit's automatic dispensing cabinet (ADC) with the default name. Vaught had to use an override function to search for it, which then presented over 40 versions of the drug, including the paralyzing agent, vecuronium. | 1. Retrieval Error: Vaught typed "VE" to search for VersEd, but selected Vecuronium. |
| Safety & Policy | 2. "Lazy" Override Policy/Culture: Staff frequently used the override feature to quickly retrieve medications not on the patient's current profile or not stocked locally, bypassing critical safety checks. | 2. Administration/Scanning Failure: Vaught failed to scan the barcode on the medication vial, which would have alerted her to the error. |
| Distraction & Environment | 3. High Stress/Workload: Vaught testified to being stressed and distracted by a trainee she was responsible for, potentially contributing to tunnel vision and failure to adhere to the "five rights." | 3. Concentration Failure: Vaught admitted to seeing the medication's name—vecuronium—in red capital letters and the warning label Paralyzing Agent, but still administering it. |
| Nursing Responsibility | 4. Failure to Monitor: Vaught did not stay to observe the patient after administering the drug. The patient was taken to the MRI suite, where she was found unresponsive. | 4. Non-Adherence to "Five Rights": Vaught violated the core safety check: Right Drug, Right Dose, Right Route, Right Time, Right Patient. |
| Hospital Protection (Cover-up) | 5. Delayed Reporting/Internal Investigation: VUMC allegedly did not disclose the full extent of the error to the state or the public for several months until an anonymous tip was reported in 2018. They reportedly settled a wrongful death lawsuit with the family. |
Sample Answer
Root Cause Analysis (RCA) of the RaDonda Vaught Case
1. Explanation and Purpose of a Root Cause Analysis (RCA)
A Root Cause Analysis (RCA) is a structured method used to understand, define, and resolve a problem by identifying the deepest underlying causes of an adverse event, rather than just treating the visible symptoms. It uses a series of processes—like the "5 Whys" or a cause-and-effect diagram—to trace back from the incident to its fundamental systemic failures.
Purpose for a Facility: The primary purpose of using an RCA in a healthcare facility is to implement systemic improvements to prevent future harm. It shifts the focus from blaming individual actions to correcting organizational processes, policies, and technological design, thereby creating a safer environment for both patients and staff.