#NurseTwitter like most of you, I've been reflecting on the #RaDondaVaught case. The only thing I'm emotional about is the loss of an innocent life. I think it is important to reflect on future practice implications now and take a long hard look at "just culture" 1/ First, we should examine two cases in the country that did not receive attention or support where a nurse was criminalized for fatal medication errors. It should be noted that this is a rare occurrence, but what is happening with RV has happened before 2/

It is important to discuss the Omnicell issue in the #RaDondaVaught case. Many nurses are accustomed to Pyxis, where each medication bin pops open to dispense. Having used the Omnicell many times, the containers are open and next to each other. It is easy to select the wrong 1/ medication. Some of the bins have missing numbers and the flashing lights to help the nurse identify the medication doesn't always work or looks like the bin above the flash when it is indeed below. This is close to my heart because this has happened to my students before 2/