PreAccident Investigation Podcast PAPod 568 - PART ONE: Charged for a Mistake: The Nurse, the Error, and a System That Failed
Oct 18, 2025
RaDonda Vaught, a registered nurse at Vanderbilt, shares her harrowing experience of a medication error that led to criminal charges. She delves into systemic issues surrounding a new EHR rollout and urgent workarounds that contributed to the tragedy. RaDonda recounts the pressure of a time-sensitive request and how distractions at the dispensing cabinet led to a misadministration of a paralytic instead of the intended medication. This candid reflection highlights the complexity of healthcare systems and sparks critical conversations about patient safety.
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Called To Give Medication Off-Site
- RaDonda Vaught was a help-all nurse at Vanderbilt and was asked to give IV Versed to a patient in PET scan while the patient was off the floor unmonitored.
- She described unit context, recent EHR rollout delays, and her limited familiarity with the patient that shaped her decisions.
EHR Rollout Created Unpredictable Delays
- A recent EHR (eStar) rollout caused intermittent delays delivering orders to the dispensing cabinet, creating frequent workarounds.
- Those unpredictable delays normalized overrides and eroded safe checks in medication workflows.
Design Quiet Spaces For Medication Picks
- Create quiet, controlled medication retrieval zones and enforce no-interruption rules when pulling drugs.
- Place dispensing cabinets away from high-traffic areas and require verification steps for high-risk medications.