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MSN 510 Week 6 Assignment: Signature Assignment
West Coast University
MSNC 510 – Advanced Nursing Technologies & Collaborative Care
Signature Assignment
In healthcare, early recognition, intervention and continuous patient
assessment are core nursing fundamentals and skills necessary to carry out safe
patient care. In conjunction with nursing skills, administrative support for the
continuous implementation of safe medical practices enables safe standards of
quality of care. However, recent medical situations have alarmed nationwide
reflection on current, or lack of enhanced safety protocols and verifications before
safety net discrepancies reach the patient. One of the more shocking cases – the
State of Tennessee VS. Radonda L. Vaught – brought a wide-shared upset,
specifically amongst nurses, with the final verdict as judgement was made to
convict Vaught of criminally negligent homicide (Lusk et al., 2022). This case
opened opportunity for healthcare organizations to revise and enhance their
current standards of practice, as well as nurse advocacy for supplemental
protection when nursing mistakes are honestly and timely disclosed.
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Trial Reflection
From the case, further investigation revealed Vanderbilt University Medical
Center (VUMC) lacked proper quality improvement measures to potentially help
avoid Vaught’s incorrect medication administration. This included feasibility on
medication override, which Vaught committed, without safety nets to verify
correct medication choice. In addition, lack of staff protection was witnessed
when Vaught immediately disclosed her mistake and requested assistance to
revert systemic medication effect. As a response, VUMC fired Vaught and failed to
report the error classifying the death as a natural cause. However, indictment was
placed solely on Vaught and not the hospital’s administration, creating a lack of
shared accountability. As a result, this leads to further invocation of fear from
clinicians to “report systemic causes and contributors to bad outcomes, removing
a foundational pillar of patient safety … [and] fear of being left unprotected and
set up for failure by the US healthcare system” (Lusk et al., 2022).
The trial and its final decision to reprimand Vaught shook the nursing
workforce as the fundamental nursing ethical principle of veracity was challenged
and shown to be attacked if exercised correctly. In response, nationwide support
from nurses was mobilized as advocates rallied in fear that the case would
influence a culture of silence in the nursing community (American Nurses
Association, 2022). This included support from the American Nurses Association
(ANA) with a letter requesting for sentencing leniency. In the letter, the ANA’s
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president, CEO and executive director described that debilitating work factors
such as demanding work environment and flawed reporting mechanisms
contributed to Vaught’s medication error (Grant et al., 2022). In her defense, this
letter outlined Vaught’s correct reporting steps in an honest and timely manner
which are expectations reflected in the nursing code of ethics. Lastly, the letter
critiques the lack of confidentiality standards that the state of Tennessee upholds
to promote reporting, which was failed to be granted to Vaught (American
Nurses Association, 2022).
Trial Applicability
This case outlined a common flaw in the healthcare system, inadequate
systems approach solutions to autonomous tasks to simplify and lessen the
burden on healthcare staff. In a systems approach, the healthcare organization is
viewed as whole holistically and it analyzes the “relationships and dependencies
between components to improve the overall performance, safety, and efficiency
of the entire healthcare system” (Komashie et al., 2021). Specifically, with VUMC,
the lack of proper health information technology (HIT) safety nets such as dual
medication verification and medication error alerts, in addition to the
encouragement of medication overrides for care delay prevention, all contributed
to the error. Although argument can be made that the nurse has ethical obligation
to verify and perform the ‘5 rights’ of medication administration, no effective HIT
systems were in place to “prevent or detect the accidental selection, removal, and
MSN 510 Week 6 Assignment: Signature Assignment
West Coast University
MSNC 510 – Advanced Nursing Technologies & Collaborative Care
Signature Assignment
In healthcare, early recognition, intervention and continuous patient
assessment are core nursing fundamentals and skills necessary to carry out safe
patient care. In conjunction with nursing skills, administrative support for the
continuous implementation of safe medical practices enables safe standards of
quality of care. However, recent medical situations have alarmed nationwide
reflection on current, or lack of enhanced safety protocols and verifications before
safety net discrepancies reach the patient. One of the more shocking cases – the
State of Tennessee VS. Radonda L. Vaught – brought a wide-shared upset,
specifically amongst nurses, with the final verdict as judgement was made to
convict Vaught of criminally negligent homicide (Lusk et al., 2022). This case
opened opportunity for healthcare organizations to revise and enhance their
current standards of practice, as well as nurse advocacy for supplemental
protection when nursing mistakes are honestly and timely disclosed.
, 2
Trial Reflection
From the case, further investigation revealed Vanderbilt University Medical
Center (VUMC) lacked proper quality improvement measures to potentially help
avoid Vaught’s incorrect medication administration. This included feasibility on
medication override, which Vaught committed, without safety nets to verify
correct medication choice. In addition, lack of staff protection was witnessed
when Vaught immediately disclosed her mistake and requested assistance to
revert systemic medication effect. As a response, VUMC fired Vaught and failed to
report the error classifying the death as a natural cause. However, indictment was
placed solely on Vaught and not the hospital’s administration, creating a lack of
shared accountability. As a result, this leads to further invocation of fear from
clinicians to “report systemic causes and contributors to bad outcomes, removing
a foundational pillar of patient safety … [and] fear of being left unprotected and
set up for failure by the US healthcare system” (Lusk et al., 2022).
The trial and its final decision to reprimand Vaught shook the nursing
workforce as the fundamental nursing ethical principle of veracity was challenged
and shown to be attacked if exercised correctly. In response, nationwide support
from nurses was mobilized as advocates rallied in fear that the case would
influence a culture of silence in the nursing community (American Nurses
Association, 2022). This included support from the American Nurses Association
(ANA) with a letter requesting for sentencing leniency. In the letter, the ANA’s
, 3
president, CEO and executive director described that debilitating work factors
such as demanding work environment and flawed reporting mechanisms
contributed to Vaught’s medication error (Grant et al., 2022). In her defense, this
letter outlined Vaught’s correct reporting steps in an honest and timely manner
which are expectations reflected in the nursing code of ethics. Lastly, the letter
critiques the lack of confidentiality standards that the state of Tennessee upholds
to promote reporting, which was failed to be granted to Vaught (American
Nurses Association, 2022).
Trial Applicability
This case outlined a common flaw in the healthcare system, inadequate
systems approach solutions to autonomous tasks to simplify and lessen the
burden on healthcare staff. In a systems approach, the healthcare organization is
viewed as whole holistically and it analyzes the “relationships and dependencies
between components to improve the overall performance, safety, and efficiency
of the entire healthcare system” (Komashie et al., 2021). Specifically, with VUMC,
the lack of proper health information technology (HIT) safety nets such as dual
medication verification and medication error alerts, in addition to the
encouragement of medication overrides for care delay prevention, all contributed
to the error. Although argument can be made that the nurse has ethical obligation
to verify and perform the ‘5 rights’ of medication administration, no effective HIT
systems were in place to “prevent or detect the accidental selection, removal, and
