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

ISMP Articles & Statements

ISMP Recommendations

Information on Just Culture and Second Victims of Errors

Ways to Support RaDonda Vaught

  • Sign a 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