On Mar. 29, RaDonda Vaught—a former Vanderbilt neuro-ICU nurse—was found guilty of criminally neglectful homicide and abuse of an impaired adult following a medication error that led to the death of a patient in late 2017. Her official sentencing is on May 13, and she is up for eight years in prison, at most.
The patient, Charlene Murphy, was in the hospital following a brain injury and was getting ready to be discharged. She was scheduled for a PET scan, which checks for tumors and masses throughout the body. Murphy was prescribed the sedative Versed to relieve anxiety during the scan, as she had expressed concern about her claustrophobia. Rather than grabbing Versed, Vaught retrieved vecuronium, a very powerful paralytic, from the computerized medication distributor. This medication was given in the scanning room and the patient’s vital signs such as heart rate and respiratory rate were not monitored during the scan, according to medical orders. Upon realization of the medication error, Murphy was already brain dead and there was nothing more that could be done.
These are simply the facts of the case that led to Mar. 29’s shocking ruling, but when looking closer at its conflicting evidence, the case becomes more complex.
There is a great amount of evidence that suggests that this mistake was not the fault of Vaught alone, but that Vanderbilt’s system played a huge role in the tragic death of Murphy. Vaught was not only honest about her mistake, but reported it appropriately through Vanderbilt Hospital. Every hospital has a process to report errors in order for the hospital to gather data about common mistakes, and to update current systems that lead to these errors. While some do not need to be reported to the state, any error that leads to a patient’s death is required to be reported so that the state can conduct an appropriate investigation.
Upon admittance of her mistake, when reporting Murphy’s death to the state medical examiner, two neuro physicians reported this as a death by natural causes, leading Murphy’s death to never fully be investigated. In hopes of there never being an investigation, Vanderbilt also protected themselves by firing Vaught and having an out-of-court settlement with Murphy’s family which barred them from speaking about the incident publicly. Similarly, as the reports are conflicting, there seemed to be problems with the electronic medical cabinets in 2017, leading nurses to override the system in order to get medications out of the cabinet more frequently than normal. Nurses testified that overriding the medical cabinet to get medication as needed was not only permitted by Vanderbilt, but was a normal practice of this time. Prior to the fatal drug mistake, Murphy’s care required at least 20 medication overrides in a matter of three days.
Vanderbilt Pharmacy commented on this testimony, saying the medication cabinets that had problems during 2017 were fixed weeks before this event and did not play a role in Murphy’s death. It is clear from all evidence that this case is not simply a single human error, but is complicated by the role of Vanderbilt hospital and all others caring for Charlene Murphy during her hospital stay.
This has led to an overwhelming response by the medical community as they stand with Vaught, terrified by the new precedent that may be set by this case. Throughout the community, the consensus is clear: Vaught should not be held solely responsible for Murphy’s death. While many do not disagree with the proceedings that took place with the Tennessee Board of Nursing, many are very worried about the responsibility that Vaught is taking alone in the eye of the law. The American Nursing Association even said that they are incredibly distressed by the new precedent set that criminalizes the honest reporting of mistakes. This has led many nurses and other health professionals to question, are they at risk of arrest for any mistake they report? Will they now be trained to stand in front of prosecution should they make a mistake? Will their hospitals protect them from human mistakes which are bound to occur in this field? The questions go on and on. Health professionals are very scared about the future of their field and what this proceeding means for the future handling of medical mistakes.
As a senior nursing student only months away from graduation, this case shocks me to my core. I have spent the last four years learning about the inevitability of mistakes and why reporting them is so critical to bettering the health care system as a whole. I have been told that my hospital will support me and they will work with me to better understand why a mistake occurred. While I have been warned that the nursing board can always revoke my license, I was reminded that I am human and I will not solely be held responsible for a mistake.
This case goes against every single thing I have been taught. While every new nurse hopes to never make a mistake, especially one that leads to the loss of life for a patient, it is always a possibility so thinking about my own fate in the face of this case is terrifying. I believe that Vanderbilt is more responsible for this mistake than Vaught, and should be held responsible as it is clear that their medication administration procedures were not appropriate. I believe that Vaught made an honest mistake and is remorseful for the pain that she has caused. I believe that she is being convicted for something that is a failure of a bigger system. I believe that she should not be found guilty and that this new precedent is dangerous not only for health care workers, but for health care systems as a whole. This is leading health care down a path where mistakes won’t be reported, and thus will run rampant, because there will be no changes to the systems which may be playing a part in these mistakes.
In only a few months, I am going to be a nurse in an ICU. I will be administering both of the medications that were mentioned in this case, tand it terrifies me to think of the consequences I may face if I were ever to make a mistake similar to Vaught’s. I am not the only health care professional that is scared.