They say the truth will set you free, but one nurse who told the truth about a medication error she committed in 2017 now faces up to 8 years in jail. On March 25, 2022, following a 3-day trial, RaDonda Vaught, a former nurse at Vanderbilt University Medical Center (VUMC), was found guilty of gross neglect and negligent homicide of 75-year-old Charlene Murphey. Murphey died as the result of Vaught administering a paralyzing agent to her rather than a commonly used anti-anxiety medication prior to Murphey undergoing a full body CT scan. Murphey, paralyzed and unable to breathe, suffered brain death while in the scanner. Vaught is scheduled to be sentenced on May 13th.
RaDonda Vaught was a registered nurse with no record of disciplinary action against her license when Charlene Murphey was admitted to VUMC on December 24, 2017, for treatment of a subdural hematoma. After Murphey’s condition improved, her physicians sent her for a CT scan in anticipation of dismissal. While in radiology, a dose of the drug Versed was ordered to calm her nerves. Vaught went to one of the hospital’s electronic medication cabinets and typed in “VE” for Versed, but no drug was dispensed. Vaught triggered an “override” feature that unlocks more powerful medications and again typed in “VE.” This time, the medication dispensed was not Versed, but Vecuronium, a powerful paralyzer. Vaught removed, prepared, and administered the drug to Murphy without realizing her fatal error. If that were the end of the story, this tragedy may not have resulted in criminal prosecution. However, there was additional evidence to support Vaught’s guilt:
- Vaught overlooked or bypassed at least five warnings saying she was withdrawing a paralyzing medication.
- Vaught did not recognize that Versed is a liquid but vecuronium is a powder that must be mixed into a liquid.
- The label of Vecuronium bears the drug’s name in large type which could not have been missed had Vaught read the label.
- To mix the drug and to draw up the dose, Vaught stuck a syringe into the vial, which required her to look directly at the bottle cap that read, “Warning: Paralyzing Agent.”
- After injecting Murphey, Vaught left the radiology department without monitoring Murphey’s response to the medication.
Vaught’s conviction – and the fact that she was charged at all – worries patient safety and nursing groups who believe that analyzing human errors and making systemic changes to prevent their recurrence improves quality of care. This will not happen under a risk of prosecution. They believe that Vaught’s guilty verdict was ultimately aided by her candor – an example of the type of culture that embraces transparency and the honest reporting of mistakes. More nurses are now convinced that owning up to mistakes will expose them to punishment. They now believe that to tell the truth is to incriminate oneself.
Two factors may serve to mitigate nurses’ fears that this will happen to them. First, this is an extremely rare case of a health care worker being criminally prosecuted for a medical error. Second, a review of available information indicates that Vaught did not commit a common medication error, but a series of errors; and her behavior arguably exceeds what one would consider to be “ordinary” negligence. Nonetheless, the case raises concerns about the impact of criminal prosecution on the culture of transparency.
It has been stated that, “the single greatest impediment to error prevention in the medical industry is that we punish people for making mistakes.” (Leading a Culture of Safety: A Blueprint for Success – Occupational Safety and Health Administration). The Agency for Healthcare Research and Quality (“AHRQ”) defines a culture of safety as one “in which healthcare professionals are held accountable for unprofessional conduct, yet not punished for human mistakes; errors are identified and mitigated before harm occurs; and systems are in place to enable staff to learn from errors and near misses and prevent recurrence” (AHRQ PSNet Safety Culture 2014). Key elements of a culture of safety in an organization include the establishment of safety as an organizational priority, teamwork, patient involvement, openness/transparency, and accountability (Lamb, Studdert, Bohmer, Berwick, & Brennan, 2003).
Vaught was transparent. Once she realized her error, she immediately reported it to her supervisors and took responsibility for her actions. She was fired from the medical center approximately 1 month later. Then, in a 2021 proceeding before the Tennessee Board of Nursing, Vaught admitted she did not double-check the drug she withdrew from the electronic medication cabinet despite multiple opportunities. She took responsibility for allowing herself to become “complacent” and “distracted” by a nurse she was training while obtaining and preparing the medication. Vaught told the nursing board, “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.” The Board revoked Vaught’s license, ending her nursing career. Vaught also admitted to the drug error when law enforcement investigated the incident. In an interview, she stated that she “probably just killed the patient.” At the time of her trial, Vaught did not testify, but the prosecution played audio recordings of her self-incriminating statements.
State and federal laws grant privileges to certain communications and analyses that take place for the purpose of evaluating and improving quality of care. Those communications are protected from discovery in civil and administrative proceedings to encourage the truthful and open exchange of information without fear of the participants incriminating themselves or others. The potential for criminal prosecution of medical errors will defeat the purpose of these privileges, however, because they do not apply in criminal proceedings.
After Vaught was charged in 2019, the Institute for Safe Medical Practices issued a statement saying it had “worrisome implications for safety.” In another statement released following Vaught’s conviction, the American Hospital Association (“AHA”) referred to the “chilling effect” this case will have on the culture of safety in health care, citing the Institute of Medicine’s landmark report To Err is Human which concluded we cannot punish our way to safer medical practices. We must instead encourage nurses and physicians to report errors so we can identify strategies to make sure they don’t happen again. The American Nurses Association (ANA) also issued a statement echoing the dangerous precedent set by criminalizing the honest reporting of mistakes. ANA also expressed concern that, in a profession that is already short-staffed, strained, and facing immense pressure, the fear of prosecution will not only cause nurses to not report errors, but it will cause them to leave the profession.
Many other professional organizations have issued statements like those represented here. In addition, thousands of nurses and other health care providers have taken to social media to express their fears and to report the impact this case has already had on nurses leaving the profession.
There is certain to be much more said about the RaDonda Vaught case following her sentencing on May 13th. Regardless of the outcome, however, many feel that the damage to the profession has already been done.