Medication Safety Alert! February 14, 2019
In this week's issue:
- Another Round of the Blame Game: A Paralyzing Criminal Indictment that Recklessly “Overrides” Just Culture
- Sidebar 1: System vulnerabilities that contributed to the error
- Sidebar 2: When did human error become a crime?
- Sidebar 3: Updated Guidelines for the Safe Use of Automated Dispensing Cabinets
- In Memoriam: Dr. John Senders
- More on fuzzy matching
ISMP was shocked and saddened to learn that, once again,1-4 a frontline healthcare practitioner has found herself on the receiving end of a criminal indictment after making a medication error that led to the tragic death of a patient. RaDonda Vaught, a 35-year-old registered nurse, was indicted on charges of reckless homicide and abuse of an impaired adult, more than a year after inadvertently administering intravenous (IV) vecuronium instead of VERSED (midazolam) to a patient in radiology. Prior to a full body scan, IV Versed had been ordered as an anxiolytic due to the patient’s...