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Radonda Vaught Is a Scapegoat
Radonda Vaught is a scapegoat. Nurses everywhere are in revolt. If you thought nursing was in trouble before (projected healthcare worker losses in the next 5 years are around 45%), nurses are choosing to quit based upon the precedent in this case.
Let us start from the beginning.
Radonda Vaught was a graduate of West Kentucky University, an experienced ICU nurse, preceptor, and leader at her hospital Vanderbilt University Medical Center. She had been employed there since 2015 with no previous incidents. She had a clean license and practiced as most nurses do; at the bedside at a hospital. One day, she was caring for her patient Charelene Murphey who was a 75-year-old with a brain bleed (technically a subdural hematoma). The medication error occurred on Dec. 26, 2017, when she was scheduled for a PET scan but was found to be incapable of lying still long enough to endure the study.
As was policy at the time and while precepting a trainee, Radonda overrode their Pyxis machine to grab versed (a sedative agent) and instead grabbed vecuronium (a paralytic agent). While practice is different everywhere, it seems that it was very common for them to give versed to patients undergoing tests if they had claustrophobia. Most hospital policies require the nurse to monitor the patient when being given a sedative, though some allow for the sedative to be given, the patient to be monitored for a short period of time (5 minutes or more), then sent to testing. All of this would depend on the doctor’s orders, the hospital policy, and common practice.
The patient appeared to the nurse to be comfortable and resting with her eyes closed.
Charelene Murphey was then sent to the PET scan unmonitored (no cardiac monitoring, no respiratory monitoring, no nurse to monitor her while in the scanner) as was ordered by the physician. Presumably, people transported her there and lifted her paralyzed body onto the gurney and into the scanner. Presumably, those people also had opportunity to notice that the patient was not breathing. However, this was apparently not the case as it has not been discussed in any articles that I have found. There are few details regarding the experiences of the transporters and radiology team, as I expect the hospital has made their position very clear to any employees involved in the case.
The patient underwent the PET scan and went into respiratory arrest, leading to cardiac arrest and anoxic brain damage. They were able to perform CPR and get a regular heart rhythm, however, 12 hours later the family was told that she was effectively left brain dead. They decided to withdraw treatment at that time.
On December 27 at 1 a.m., Charelene Murphey was declared dead.
Important points to note:
- Radonda Vaught never tried to hide her medication error. She reported it immediately to the physician in charge of her patient. She was devastated by her error.
- Vaught was investigated by the Department of Health, which licenses nurses in Tennessee. They declined any disciplinary action after their investigation in 2019. There are other sources about how she also faced this disciplinary case brought by the Department of Health, after the case became public due to an “anonymous tip”.
- Vaught is quoted as saying that at the time of Murphey’s death, Vanderbilt was instructing nurses to use overrides to overcome cabinet delays and constant technical problems caused by an ongoing overhaul of the hospital’s electronic health records system which was slow and incomplete.
- The physician in the case had ordered that the patient could go to the test unmonitored; if monitored, the error would have been apparent and rescue could have been performed more immediately.
- Two neurologists indicated on the death record that the death was of “natural causes”, not from a medication error. The error was known at this time but was obscured by the hospital.
- A Vanderbilt hospital doctor indicated that “(The patient) got such a small dose, and he/she was anxious about the test, so we can’t say it contributed to his/her demise.”
- It is entirely possible that the medication was not the sole cause of death, although it is probable.
- Murphey’s death resulted in the hospital’s Medicare reimbursement status being jeopardized, pending investigation and corrective action.
- Vanderbilt was already at risk due to other pending civil suits regarding varied errors such as: operating on the wrong kidney, removing the entire thyroid of a patient and losing it, accidentally puncturing the carotid artery of a patient and not reporting it to the family and the patient subsequently died, removing less than 20% of a pituitary tumor and declaring it “maximally resected” with no follow-up imaging prior to DC…. and the list goes on.
- Medication errors are very common in the hospital environment and include such diverse things as: giving the wrong medication, giving the correct medication late, not assessing the patient properly prior to administration, not assessing the patient properly after administration, giving the correct medication through the wrong route, and even preparing the medication incorrectly.
One can look at any licensing board if one enjoys looking at disciplinary actions and causes. Nurses, physicians, pharmacists, and other practitioners regularly have their licenses suspended or removed given various grievances. When convicted of a crime, one may also lose their license since they usually require federal clearance in order to practice.
Having professional newsletters delivered regularly, my family is privy to a number of the details of these cases. In discussion with my father (California Pharm D. for almost 45 years now with a current license), he was quite shocked about Vaught’s discipline. Given how often physicians and pharmacists give the wrong doses, mix the wrong medications, and perform pretty egregious oversights and wind up with merely a suspended license, rather than criminal charges, he was shocked. He was not familiar with the case, but will be providing me his opinion in short order (once he has a minute away from caretaking duties).
I have to agree.
I have seen doctors, personally, do things that I would question. They are still practicing. To my knowledge, they have not been suspended. Some have been sued in civil court, but have defended their practices fairly well. A number of them are wrongfully accused of negligence. A number of them are never accused at all. Frankly, that surprises me sometimes. I have never heard of a physician having criminal charges pressed for a genuine error that was not made while under the influence or so grossly negligent that it was criminal. It is so rare that when googling, I came across only one article which references NYT back from the ’90s.
Nurses are a fractious lot.
We do not often pull together. Despite the pandemic, nurses still had their dividing lines: masking/no masking, vaccines/no vaccines, shutdown/life as normal, politics, unions/anti-union, abortion, euthanasia. Even other more petty dividing lines: day shift vs. night shift, outpatient vs. inpatient, floor nurses vs. emergency nurses, ICU vs. emergency, doctors vs. nurses, old nurses vs. new grads, nurses vs. other nurses.
As I said, there is a whole lot of infighting.
It is astonishing that nursing organizations, which rarely unify for the best of nurses and instead are usually just political lobbyists, have released statements in support of Radonda. Even the ISMP (Institute for Safe Medication Practices) President was quoted in an article regarding the various systems errors that had to occur to even allow Vaught to make the error.
Nurses everywhere are second-guessing their choices in career. As this is becoming a bit of a trend, nurses are turning in their badges.
Pay that does not keep up with inflation. Impossible standards for patient care. No time for personal care. Inability to perform up to one’s standards due to patient pressures, staffing, and administrative demands. And now criminal culpability for honest mistakes? Even when there is no attempt to obfuscate? Malpractice insurance does not cover criminal charges and nurses do not make enough to retain an attorney just in case a DA determines that they need an easy win to pad their prosecution record.
Why bother?
Nurses are not just leaving for their sanity.
Now they are leaving for their freedom.
Somewhat related: Radonda Vaught is also being charged with perjury for incorrectly filling out paperwork to receive two rifles. She did not indicate that she was under indictment for a felony, which would have made her ineligible to receive the weapons. Her husband and she own a hunting business. She has been noted as a supporter of 2A on social media. Had she taken the stand, the DA intended to question her honest and integrity in this matter.
Articles of interest on the case or about nurse malpractice:
https://ajnoffthecharts.com/case-of-nurse-charged-with-homicide-for-medication-error-raises-concerns/
https://www.tennessean.com/story/money/2018/11/30/vanderbilt-patient-death-medication-error-medical-examiner/2155152002/
https://www.bigcountryhomepage.com/news/nashville-da-on-radonda-vaught-case-verdict-is-not-an-indictment-against-the-nursing-profession/
https://www.npr.org/sections/health-shots/2022/03/25/1088902487/former-nurse-found-guilty-in-accidental-injection-death-of-75-year-old-patient
https://www.usatoday.com/story/news/health/2021/07/23/ex-vanderbilt-nurse-radonda-vaught-loses-license-fatal-error/8069185002/
https://www.usatoday.com/story/news/health/2019/12/15/vanderbilt-vumc-radonda-vaught-medication-error-vecuronium-charlene-murphey/2454711001/?gnt-cfr=1
Published in Healthcare
All I can say, is “wow.” How sad.
It’s not just doctors who get away with it. If we’re prosecuting medical mistakes, someone needs to contact Andrew Cuomo.
I can’t add anything to this post other than it is a sad day for the nursing profession.
Edited to add: It will be interesting to see how hospitals respond to this. Why do I get the feeling it will be even more CYA and as usual more useless protocols and classes. Not helping with reducing workload in any manner of ways. But by all means, let’s add another layer of bureaucracy and management.
That is a policy mistake. Kill enough people under a large enough title and it no longer becomes criminal, apparently. Then it’s just “bad policy”. I guess no one likes to charge for mass murder.
As my mother asked me countless times in my childhood “How do you know you don’t like it if you haven’t tried it?”
But it could also be a “cautionary tale.” Just think what the Left would have liked to prosecute Trump for, they would have loved to charge him with “murder” for everyone who died of/with covid during his time. Just for starters.
I found this article helpful in making sense of what all happened when.
The NPR story mentioned that vecuronium is a powder. How do you even inject a powder?
You have to dissolve it in distilled water first.
I found it was missing a lot, such as that the doctor had ordered “no monitoring” when the patient was being moved, but why was that? And why wasn’t it changed if it was known that she was given the wrong drug?
If it’s not all that rare for someone to be given the wrong drug or the wrong dose or something, why would it seem to be policy to not do anything to correct it, or even to allow for monitoring afterward if a pre-mistake order said it wasn’t necessary?
There are a lot of links in the article. I mean a lot, including the report from CMS. I think is will answer some of your questions. This is also part of the problem here. As TRN has stated, this nurse is the scapegoat for a lot of issues.
If it’s a powder, just add liquid.
Thanks. I guess the next question along those lines is if Versed is always a liquid or sometimes a powder, but I think I really don’t want to play prosecuting attorney here (or on TV). Let’s just say that I’m not heartened by the notion that medication mistakes happen all the time.
Yes, but your comment referred to just the article, and I found that the article was missing a lot. Seems to me it should have included a lot more, without having to go to other referenced articles.
What it comes down to, though, is yes, she is being made a scapegoat. About all the hospital could do was pay money, which they did. And that really should have been the end of it. But RaDonda Vaught is one of the only, if not THE only, people who could be specifically identified. Once identified, all eyes turned to her. She was operating within a fatally (as it turned out) flawed hospital system, as shown by the hospital making changes to satisfy CMS etc. Which should have been taken into account for her but probably wasn’t.
Well, if it makes you feel a little better, as TRN points out, there are lots of things that are considered errors. Most of which amount to no harm, but are still supposed to be reported in the hopes that whatever caused it can be corrected so as to not happen either frequently or at all. Thus the reason nurses feel that this verdict will now cause errors to go unreported which is not a good thing.
Yeah, I get that, and also that “we want no errors ever” is about as feasible a proposition as “we want no traffic fatalities ever”. It’s just that stopping and thinking about it isn’t much fun.
The single biggest mistake to me, because it was likely more unrecoverable than the others, was the “no monitoring” thing while transporting the patient. Even if the doctor thought that was okay before, it should have been changed. And that it wasn’t changed, doesn’t seem to be RaDonda Vaught’s fault.
If I “leave the oven on” at home, but when I go back to turn it off someone prevents me from doing so, and the house burns down perhaps causing deaths, I think responsibility was shifted to the person who blocked corrective action.
Out here, Vandy’s where you go when you need serious medical attention.
This makes me wonder.
I don’t think I would wonder or worry about a nurse possibly making a mistake, I would be concerned that an earlier decision by a doctor would not be overruled even if the situation has clearly changed.
As a hospital pharmacy technician (lead IV tech), none of my mistakes ever made it out of the pharmacy, and I made precious few mistakes. I caught another tech making a mistake that would have been fatal for the patient if it had been allowed to leave the pharmacy (reconstituting an antibiotic powder with Potassium Chloride instead of sterile water).
You’re probably right.
I had an interesting experience years ago. One day I was following a big truck through a narrow two-lane busy road that became a one-lane road. I was right behind the truck and saw the driver graze (sideswipe) a little car to its right when the road became one lane.
It was really horrifying to watch. The truck just kept going, to the terror of the occupants of the little car. I was honking my horn furiously, but the truck didn’t stop. Instead, it turned down the first road on its left and disappeared.
I wrote down the license number and immediately went to the local police department and reported it.
I was talking to my husband about it later. I said, “I don’t understand why he didn’t stop. He had to have known he was harshly sideswiping the little car, even though it was in his blind spot. He’d have felt his truck hitting that little car. And I and other drivers were honking our horns at him.”
My husband said, “That’s because of the latest revisions in the drunk-driving laws in Massachusetts. The penalty for leaving the scene of a sideswiping accident is peanuts compared to what would have happened to him if he had had as little as a single beer for lunch.”
I would not sweat it. I am sure there are plenty of immigrants willing to take nursing jobs. That is how they nailed us in IT.
It’s a sad story and, yes, the criminal prosecution seems extreme. It does sound like her mistake involved a lot of negligence, and I don’t know at what point one becomes criminally liable — how many mistakes can accumulate to lead to a fatality before it stops being a matter of simple medical malpractice and becomes something warranting a criminal trial.
I read a lot of professional assessments of potential malpractice cases because I proofread for a friend who is a cardiac/thoracic surgeon and is often called upon to render a professional opinion. Though I’ve read many such assessments, I’ve rarely encountered an example of malpractice as apparently unambiguous as this one, though perhaps that has to do with the inherent variability of critical surgery compared to the obviousness of this particular error.
I assume a mistake of this magnitude is relatively rare. I certainly hope it is.
As I wrote before, I think a good portion of the blame shifts to anyone who didn’t monitor the patient once it was known that the wrong drug was given. Even if her doctor/surgeon said monitoring wasn’t needed UNDER NORMAL CIRCUMSTANCES, once those circumstances were no longer normal, I’d call it at least potentially criminal – criminal negligence, still/again – to still not using monitoring just because a surgeon didn’t specifically order it.
In defense of the doctors and protocol, it is not uncommon for patients (even monitored ones) to be unmonitorex for 10-30min for a test. This is particularly true if they are no longer in critical care. Since the patient had been stable, was likely to be downgraded, transferred and discharged, it was not entirely uncommon for doctors to say the patient could go unmonitored for this brief period of time.
I have personally seen patients go unmonitored who shouldn’t (imho) and patients go monitored when that’s a gross overestimation of their acuity.
Again, these things are often a mater of judgement, protocol, and, frankly, staffing. I know that people request patients to go unmonitored by physician’s order because we simply do not have the staff.
And this is in CA, the mecca of all nurses (because of mandated ratios and breaks).
Even CA is not perfect.
And everyone else: this should [expletive] scare you. Because even with ratios. Even with breaks. People are *exhausted*. And that’s 1/50. Your 49 better have private duty nurses in the hospital because I can guarantee that despite our best efforts, we cannot provide the necessary care.
And nurses who say they can are lying.
Yeah. I said it. Because with these guidelines, there isn’t enough time in the day for it. So something isn’t adding up.
And at the end of the day, we know the math. Hopspitals: 100. Nurses:-100
If you think the nurses had not already complained, you are wrong.
TikTok (that crazy Chinese app) is full of nurses with stories that would shock you. I recommend you create a junk email and join. Look up @thenurseerica, look up @sassynurse2021 for humor and just let the algorithm take you.
You will learn things…. maybe you didn’t want to know.
But you will learn.
That wasn’t my point, my point was that RaDonda Vaught was the only individual target they had, although it was actually the fault of the hospital/administration but they could only pay money which they did. Which really should have been the end of it. But someone wanted to blame a person, and the hospital/administration threw her under the bus, or to the wolves, or whatever the kids say now.
You proofread what, exactly? When a *doctor* is asked for a professional opinion?
And how is the malpractice as unambiguous as this one?
Because… what? Because she didn’t read the override when distracted? Because she still didn’t get it when she read the dilution instructions? Praytell, from your expert reading experience, what you know?
Absolutely.
They did. And so there’s no information.
Because the civil suit compells silence.
@therightnurse
This is exactly why heavy industry moved away from blaming the individual. People, even highly skilled and dedicated professionals, make mistakes. That is as inevitable as death and taxes. If you want to eliminate adverse events, you need to redesign the system. I can see numerous root causes here, starting with malfunctioning Pyxis. You never want people to casually bypass a safeguard / control system. Do nurses verify the medication they are administering when they prepare to give it to the patient? Even if we assume a functioning Pyxis, the pharm tech could have accidentally loaded the wrong medication. The failure to monitor the patient was another safeguard bypassed – there is always the potential for an idiosyncratic reaction, especially if the patient has never received this sedative before.
As the incident investigator, I would look at the response once the medical error was detected, and how the medical error was eventually discovered.
The only time where a worker should be punished for an error like this is when the worker made the situation worse than another worker making the same mistake.
Medical errors killed my mother, and nearly killed my stepmother. It is vitally important that they be addressed with the same kind of approach used in the nuclear industry, air travel, and chemical process safety.