TCOM leading the way in patient safety
April 28, 2022

Vanderbilt nurse RaDonda Vaught was chatting with a mentee the day after Christmas in 2017 when she typed the first two letters of her patient’s prescription into the drug cabinet monitor: V-E.

She wanted Versed, a sedative to help the 75-year-old patient — a woman hospitalized for a brain bleed — relax before her final scan. Instead, she selected vecuronium, a drug that causes paralysis. Vecuronium was Vaught’s top search result, and she didn’t check the label before administering it.

Within the hour, her patient had no pulse. In fewer than 12, she had died. Later, the patient’s medical examiner report would identify her cause of death: acute vecuronium intoxication, an error for which Vaught would, just last month, be criminalized.

In the decades since patient safety surfaced as a research priority, no official count of accidental patient deaths exists, but some experts estimate the number in the U.S. could be in the hundreds of thousands each year. “The system is not improving,” said Lillee Gelinas, a nurse and course director for patient safety at the Texas College of Osteopathic Medicine. “And you have to back up and say, ‘Why?’’”

Since 2019, before Vaught’s conviction swept national headlines, Gelinas and her colleagues at the medical school have worked to answer that question. One solution, she said, is academic — which is why, in 2020, the Texas College of Osteopathic Medicine became the only medical school in the world to require its students to take the internationally recognized Certified Professional in Patient Safety exam.