RaDonda Vaught, medication safety, and the profession of pharmacy: Steps to improve safety and ensure justice

The prosecution and ultimate conviction of nurse RaDonda Vaught is both a warning and a call to action for pharmacists and the profession of pharmacy. This essay outlines nine steps that should be taken to maximize patient safety and minimize the risk of criminal prosecution for harm that results from human error. These include advocating for safe practices that reduce the risk of wrong drug errors; using pharmacy professional organizations to educate prosecutors about just culture and system safety; strengthening the focus on at-risk behaviors and the normalization of deviance; training a cohort of clinicians to serve as expert witnesses for the defense; embracing communication and resolution programs as responses to unexpected harm; encouraging and supporting conservative medication use to minimize exposure to medication risks; drawing attention to production pressures and their impact on patient safety and clinician burnout; promoting proactive surveillance for adverse drug effects; and standing in solidarity with other health professions, especially nursing.