instructions: replies should be a minimum of 2 paragraphs each. 

 Peer 1 : A legal nursing issue that sticks out to me is the case of redound Vaught, a Tenessee nurse that made a deadly medication error and whose case made headlines when she was charged criminally for her actions. This case was all over the news while I was in nursing school and caused me to take a serious look at how this kind of error could occur.

Malpractice is a legal term that anyone who works in the medical field is familiar with. It is described as “professional misconduct, unreasonable lack of professional skill, or failure to adhere to the accepted standard of care that causes injury to a patient” (Burkhardt, 2020, p. 126). Nurses are expected to make decisions according to their experience and education and can be held liable when it is deemed that there has been a breach of duty to the patient. When a nurse is licensed they are deemed to meet a certain proficiency and must follow the standard of care outlined for them from the state licensing board, their own facility policies, federal laws etc. (Burkhardt, 2020). Vaught made many errors when she mistakingly administered a paralytic to her patient instead of a sedative for anxiety. The legal case that followed determined that this went beyond medical malpractice and Ms. Vaught was charged with 2 felonies.

Vaught made a series of missteps and as a “reasonable and prudent nurse” these actions could have been avoided. She ignored alerts within her electronic medication system that indicated she was withdrawing the wrong drug, she failed to recognize the drug she was administering and she failed to properly monitor the patient after the drug was administered. The medical field has taken a good look at how to decrease the number of preventable errors in medicine. In 1999 the Institute of Medicine published To Err Is Human a report which argued that “errors are due not solely to individual health care providers but also to systems that need to be made safer” (Lamas, 2022). Mistakes are always going to occur, so how can we learn from them. 

Vaughts error falls under the category of the National Quality Forum’s “never events” initiative. This initiative recognized 28 “serious reportable events, which are so unambiguous, serious and preventable that they should never happen” (Burkhardt, 2020). One of the 28 never events is “patient death or serious injury associated with a medication error”. When Vaught administered that paralytic it was a failure in the system. She ignored many of the things that we are taught in nursing school including the rights of medication administration and that combined with her claims of being over worked and distracted led to the death of a patient.

As an outsider looking in there are so many glaring mistakes and ways that this could have been prevented, most of which the hospital had in place. There were claims that their electronic medication distribution system was malfunctioning, as someone who works in the ER of an underfunded community hospital, I find that completely plausible. There isn’t a moment that goes by when I am on the floor that I am not aware that I am just as vulnerable as Vaught was that day. I use her case as a reminder to not take shortcuts, to look up medications if I am not familiar with them and to remain steadfast and competent in my career as a nurse.

peer 2 : 

 A nurse is currently under investigation after various patients have become ill due to fentanyl being replaced with water during their care. The incident occurred at the Asante Rogue Regional Medical Center in Oregon, where suspicion of medication theft was reported. As a result, a concern for adverse patient care occurred, with the impact on the patients still being monitored and deaths being investigated. In this case, patients could have acquired infections due to the introduction of tap water into their system.

 In this example, the nurse falls under professional negligence as she failed to do what another reasonable nurse would have done in her position (Burkhardt, 2020). This nurse did not ensure the safety of her patients and acted in a way that not only did not follow the plan of care but violated their welfare. Additionally, as a nurse, the individual has committed malpractice as she committed negligence in a professional capacity and failed to adhere to the standard of care, causing injury to multiple patients. (Burkhardt, 2020).

 Malpractice within the healthcare field can be mitigated by using safety standards to prevent injury. The Joint Commission has outlined safety goals that healthcare providers, specifically nurses, can implement to create a safer practice environment (Rodziewicz et. al., 2023). Such safeguards include medication labels on all medications and proper identification of patients prior to administration. In this case, although the medication was labeled and the patient was identified, the nurse tampered with the medication. This action caused the safeguard to fail. In this case, requiring a cosigner when scanning the medication and programming the pump to minimize tampering risk may have been beneficial. Conversely, safeguards such as reporting discrepancies or any unexpected occurrence successfully prevented further injury by the nurse. 

 Although this nurse was reported and injury has already occurred, performing a root cause analysis is vital. A root cause analysis can help identify what factors contributed to these events and how to prevent them in the future (Rodziewicz, et. al., 2023). In this case, further insight into the nurse and the circumstances behind her actions can help identify other staff struggling to perform and meet the standards of practice. Examples can include substance abuse that is triggered by other emotional means, such as depression, anxiety, or previous health issues. Additionally, the units and the workplace environment will be assessed, and how management is involved in maintaining the well-being of their staff will be assessed. Unfortunately, the shortage of nurses is increasing the workload, which leads to fatigue, mistakes, and countless other factors that can negatively impact patient safety. In this case, drug testing on staff was not confirmed by Asante (Battaglia, 2024). These types of safeguards can help identify at-risk staff and allow management to intervene before events such as these take place, risking the lives of patients within the facility.

 In this case, the loss of life and patient injury could have been avoided. Once the investigation is complete, further details may highlight weaknesses in the hospital’s and the Joint Commission’s safeguards. Changes will be made and hopefully will have a positive impact by preventing further injury.