Resources Related to Neuromuscular Blocker and ADC Errors

The criminal conviction of former registered nurse, RaDonda Vaught, for her role in a fatal medication error has gained national attention. ISMP believes the jury was not made aware of system failures that helped promote this error instead of preventing the individual (nurse) from committing the error.

Below are links to resources related to preventing errors with neuromuscular blockers and automated dispensing cabinets (ADCs), to help healthcare organizations reassess and address issues in their own facilities. Links are also included to information on Just Culture, second victims of medication errors, and why the five rights of medication use, which were mentioned during the trial, do not work.

On-Demand Webinar

• Lessons Learned about Human Fallibility, System Design, and Justice in the Aftermath of a Fatal Medication Error

ISMP Articles & Statements

• Criminalization of Human Error and a Guilty Verdict: A Travesty of Justice that Threatens Patient Safety
• Paralyzed by Mistakes- Reassess the Safety of Neuromuscular Blockers in Your Facility
• Safety Enhancements Every Hospital Must Consider in Wake of Another Tragic Neuromuscular Blocker Event
• When Did Human Error Become a Crime?
• The Five Rights: A Destination Without a Map
• ECRI and ISMP Public Statement | Medication Errors are Complex; Criminal Charges Will Not Improve Care

ISMP Recommendations

• ISMP Targeted Medication Safety Best Practices for Hospitals (see practice #7)
• Guidelines for the Safe Use of Automated Dispensing Cabinets

Information on Just Culture and Second Victims of Errors

• Just Culture, Medication Error Prevention, and Second Victim Support Needed in Nursing Curriculum (Article)
• Just Culture, Medication Error Prevention, and Second Victim Support: A Better Prescription for Preparing Nursing Student for Practice (White Paper)
• The Differences Between Human Error, At-risk Behavior, and Reckless Behavior are Key to a Just Culture (Article)
• Too Many Abandon the "Second Victims" of Medication Errors (Article)
• Just Culture Company Resources on Vaught Case (Website)

Ways to Support RaDonda Vaught

• Sign a Change.org petition to grant RaDonda clemency
• Write a letter to the Tennessee Governor, Bill Lee (address: Bill Lee, Tennessee Governor, State Capitol, 1st Floor, 600 Dr. Martin Luther King Jr. Blvd., Nashville, TN, 37243)
• Write a letter to Judge Jennifer L. Smith of the Davidson Country Criminal Court Division IV (address: RaDonda Vaught, P.O. Box 128, Bethpage, TN, 37033); include RaDonda Vaught's Case Number (2019-A-76); explain what your job is and how this impacts you