“Freedom is not worth having if it does not include the freedom to make mistakes.” ~Mahatma Gandhi
Radonda Vaught, a 38 year old critical care nurse of Bethpage, Tennessee, has faced criminal prosecution and eight years of imprisonment due to a fatal drug error performed on Charlene Murphy, 75, at Vanderbilt University Medical Center in 2017. Vaught has been charged with gross neglect of an impaired adult and negligent homicide after she accidentally administered a paralytic agent, Vecuronium instead of the prescribed Versed, a sedative indicated for a routine PET scan. This story has grappled readers across the United States with every twist and turn, leading nurses to question the greater implications of their career.
A key point in this case is the dishonorable nature of the hospital administration as an attempt to conceal the mistake. After Vaught practices honesty and confesses responsibility for the medication error, Murphey’s death is reported to the medical examiner with no mention of the medication error, and she is presumed dead of natural causes of her initial diagnosis of a subdural hematoma. Vaught became responsible for creating a medication override in the automated medication distributor when she pulled Vecuronium instead of Versed. However this had become a standard expectation in the practice of care.
Once the error was discovered, Murphey was found brain dead after her scan was complete. Vanderbilt then fired Vaught and the administration failed to report the medication error to state or federal officials, required by law. Vanderbilt officials then offered an underhanded settlement to the Murphey family that requires complete secrecy of the medication error or true cause of death. In October 2018, state and federal officials received an anonymous tip about the true devastation of the medication error, and legal action ensued against Vaught and The Vanderbilt Medical Center. The stark difference is Vanderbilt Medical Center continues to operate with a minor penalty, while Vaught is stripped of her license, her dignity and has become the face of a worse case scenario for nurses everywhere.
Statements from nursing associations across the country, such as The American Nurse Association, the National Medical Association and the American Association of Critical Care Nurses all highlight the dangerous and disheartening statement the recent conviction sets upon nurses and the healthcare industry as a whole. The American Association of Critical Care Nurses states, “This criminal prosecution and verdict will negatively impact the timely and honest reporting of errors. In addition, this case has further demoralized an already exhausted and overworked nursing workforce in the face of existing nurse staffing shortages.”
Nurses are the backbone of our medical system. They are fearless advocates for patients everywhere, leading others with resilience and compassion that can only be found in the nursing vocation. They are the brave hand holders, the empathetic problem solvers and pioneers in evidence-based practice. As nursing conditions deteriorate with unsafe staffing ratios, widespread burnout, demand for longer hours and hospital malpractice, nurses are stacked with unrealistic demands. This perpetual burden leads to inevitable fatal medication errors and extremely unsafe conditions for nursing staff and patients. According to statistics from the World Health Organization, “In high-income countries, it is estimated that one in every 10 patients is harmed while receiving hospital care. The harm can be caused by a range of adverse events, with nearly 50% of them being preventable. Medication errors are a leading cause of injury and avoidable harm in health care systems: globally, the cost associated with medication errors has been estimated at US$ 42 billion annually.” Preventable deaths can be amended by policy reform of strict staffing ratios and facilitating a culture of safety without the fear of criminal consequence.
Without a doubt, this deadly precedent will deter nurses from ever reporting medication errors or unsafe working conditions with fear of having their license revoked. Vaught immediately admitted her error and has expressed continuous remorse over her offense, stating, “I know the reason this patient is no longer here is because of me. There won’t ever be a day that goes by that I don’t think about what I did” during her trial. Vaught took all the necessary steps, ensuring transparency and personal responsibility for the error she created. However, she was slapped in the face with a criminal conviction and was abandoned by the hospital administration. It is obvious that Vaught made a deadly error and should be punished accordingly. However, a nurse who makes a mistake is not a criminal, she is a human.
No healthcare worker, no matter how diligent and skilled, is immune to medication errors. A wave of dread has fallen over the healthcare community after the bleak outcome of the Vaught vs. Tennessee trial. Nurses everywhere have been speaking out about their history of mistakes, with the widespread belief that this could have been me.
Nurses marched under “Heroes Work Here!” signs after the devastation of the COVID-19 pandemic. Now, we’re the inmates behind bars. The precedent is determined by greed, deceit and manipulation. There is no freedom without the freedom to make mistakes and there is no advancement in patient care without an accepting atmosphere and humane treatment of nurses.
The nursing vocation will forever be tainted with the painful memories of this somber outcome. In the future, we must facilitate a culture of understanding among our healthcare team by solving problems systematically. Failure of this will result in history repeating itself and more patient suffering.