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In Depth – Nurse Convicted of Neglect and Negligent Homicide for Fatal Drug Error

While the trial is over and the verdict handed down, the discussion on the event and its repercussions are ongoing, so I’ve elected to devote this entry in the In Depth series to the story of a former nurse convicted of gross neglect of an impaired adult and negligent homicide resulting from a fatal drug administration error that occurred in 2017.
The admittedly abbreviated facts are these, as summarized by The Advisory Board (3/28/22):

In 2017, RaDonda Vaught, RN, withdrew a vial from an electronic medication cabinet and administered the drug to Charlene Murphey, a 75-year-old patient.

Unfortunately, instead of grabbing Versed (midazolem), a sedative to help calm Murphey before she underwent a scan, Vaught accidentally grabbed vecuronium, a powerful paralyzer that stopped the patient’s breathing and left her brain dead before the error was discovered. Murphey ultimately died on Dec. 27, 2017.

Following the fatal error, the Tennessee Board of Nursing in 2021 revoked Vaught’s RN license, effectively ending her nursing career. At the hearing, Vaught admitted her mistake, saying she had become “complacent” in her job and was “distracted” by a trainee while using the computerized medication cabinet.

Vaught was criminally charged with reckless homicide and gross neglect of an impaired adult.

There were a number of contributing factors that came to light during the investigation.

Human factors included
  • Vaught was accompanying a patient from the ICU to radiology.
  • A trainee was shadowing her.
  • Vaught typed in “ve” (for Versed) into the dispensary instead of “mi” for midazolam
  • Vaught overrode the system’s refusal to dispense with an override
  • Vaught failed to note that Versed is a liquid and vecuronium (which we withdrew from the system and failed to pay attention to the label) needs to be reconstituted.
System factors included
  • The medication dispensary in radiology was not communicating with the facility EHR
  • Radiology did not have a wristband scanned in the department
A combination of human and system factors includes
  • The “right patient, right medication, right dose” procedure was not followed (see above: wristband scanner)
  • The “two nurses agree” policy was not followed.
  • The order, intended to account for patient anxiety during the scan, as not integrated into the dispensing system
  • After administering the medication, that patient was not monitored or assessed in advance of the scan.

As noted above, the patient died, Ms. Vaught admitted the error, and was fired.

I think it’s important to pause for this:

I’ve not seen this mentioned in most mainstream accounts the absolutely terrifying way Ms. Murphey died. Awake. Paralyzed.  Suffocating.

Granted, Ms. Vaught seems to be genuinely sorry for causing her death, but the story does contain a cautionary tale about the consequences of one’s actions.

It is reflected in several accounts that the hospital settled with the family and several years went by…

..at which point an anonymous tip prompted an investigation into both the hospital and Ms. Vaught.

As is noted above, Ms. Vaught lost her nursing license and was thereafter charged with several very serious criminal offenses.

Again, most contemporary accounts focus on the disparity between the serious impact on Ms. Vaught and the seemingly modest effect on her employer, but we’ll set that aside and continue with the story. In this case, the trial and conviction – and then the aftermath.

The Advisory Board reported details from the trial:

During the trial, the prosecution argued that Vaught irresponsibly ignored several warnings when obtaining medication. “This wasn’t an accident or mistake as it’s been claimed,” said Assistant District Attorney Chad Jackson. “There were multiple chances for RaDonda Vaught to just pay attention.”

Vaught’s attorney, Peter Strianse, argued that Vaught made an honest mistake, saying she couldn’t have behaved “recklessly” if she believed she was giving her patient the right medication, adding that there was “considerable debate” over whether the vecuronium killed Murphey. Strianse added that Vaught was being used as a “scapegoat” for problems related to VUMC’s medication cabinets.

Leanna Craft, a nurse educator at the neuro-ICU unit at VUMC, said it was common for nurses to override the system to get drugs, as there were often delays in retrieving medications from the automatic drug dispensing cabinets.

However, Terry Bosen, VUMC’s pharmacy medication safety officer, testified that while VUMC had some technical errors with its medication cabinets in 2017, those issues were fixed weeks before Vaught used the wrong medication on Murphey.

Donna Jones, a nurse legal consultant, testified that Vaught violated the standard of care nurses are expected to maintain. Vaught not only grabbed the wrong medication but also failed to read the name of the drug, notice a red warning label on the medication, and stay with the patient to see if they had an adverse reaction, Jones said.

And Kaiser Health News (3/25/22) reported on the outcome:

RaDonda Vaught, a former nurse criminally prosecuted for a fatal drug error in 2017, was convicted of gross neglect of an impaired adult and negligent homicide Friday after a three-day trial that gripped nurses across the country.

Vaught was acquitted of reckless homicide. Criminally negligent homicide was a lesser charge included under reckless homicide.Vaught faces three to six years in prison for neglect and one to two years for negligent homicide as a defendant with no prior convictions, according to sentencing guidelines provided by the Nashville district attorney’s office. Vaught is scheduled to be sentenced May 13, and her sentences are likely to run concurrently, said DA spokesperson Steve Hayslip.

Again, a pause, as – again – few accounts mention the concept of Just Culture, and it has, in my opinion, pertinence here.

 

The Oschner Journal, linked here via the National Library of Medicine, offers a concise definition.

A just culture balances the need for an open and honest reporting environment with the end of a quality learning environment and culture. While the organization has a duty and responsibility to employees (and ultimately to patients), all employees are held responsible for the quality of their choices. Just culture requires a change in focus from errors and outcomes to system design and management of the behavioral choices of all employees.

We will return to that goal in a bit.

As I write this (recall, this is a developing story), the backlash to the verdict is widespread and vehement.
From NPR:

Vaught’s trial has been closely watched by nurses and medical professionals across the U.S., many of whom worry it could set a precedent of criminalizing medical mistakes. Medical errors are generally handled by professional licensing boards or civil courts, and criminal prosecutions like Vaught’s case are exceedingly rare.

Bruce Lambert, a patient safety expert and director of the Center for Communication and Health at Northwestern University, who was interviewed before the verdict, said Vaught’s case was extremely concerning.

“This will not only cause nurses and doctors to not report medication errors, it will cause nurses to leave the profession,” Lambert said.

“What’s happened here is that health care has been completely changed,” said Janie Harvey Garner, founder of the nurse advocacy organization Show Me Your Stethoscope. “Now when we tell the truth, we’re incriminating ourselves.”

 

and, perhaps most notably, from Kaiser Health News: Why Nurses Are Raging and Quitting After the RaDonda Vaught Verdict, which includes this excerpt:

In the wake of Vaught’s trial ― an extremely rare case of a health care worker being criminally prosecuted for a medical error ― nurses and nursing organizations have condemned the verdict through tens of thousands of social media posts, shares, comments, and videos. They warn that the fallout will ripple through their profession, demoralizing and depleting the ranks of nurses already stretched thin by the pandemic. Ultimately, they say, it will worsen health care for all.

and this one:

Linda Aiken, a nursing and sociology professor at the University of Pennsylvania, said that although Vaught’s case is an “outlier,” it will make nurses less forthcoming about mistakes.

“One thing that everybody agrees on is it’s going to have a dampening effect on the reporting of errors or near misses, which then has a detrimental effect on safety,” Aiken said. “The only way you can really learn about errors in these complicated systems is to have people say, ‘Oh, I almost gave the wrong drug because …’

“Well, nobody is going to say that now.”

This brings us back to the concept of Just Culture.

It is absolutely evident that Ms. Vaught made an error, and that error caused the death of Ms. Murphey.

She admitted that this was the case.

What is at issue is why, the nature of the consequences of that action,…

…and what we can do so that it does not happen again.

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Paul Hudson, FACHE
Chief Operating Officer
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