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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
Fiction …plus it wasn’t failure-it was deliberate.
Is it just me, or is this another example where our modern society wants to make accidents criminal?
Lately it seems our society has accepted some sort of idea that if everything is done just right, then nothing bad is going to happen and everything will turn out well. It manifests in different ways. The Left tends to micromanage our lives through legislation and regulation, the Right tends to create formulae based on the right way to do things that will ensure success. Overall it strikes me as a secular version of works-based salvation on a material level.
Things don’t always go right, and mistakes are bound to happen. Lately we seem a less tolerant of mistakes and that doesn’t seem a good direction to me, especially as if one is too afraid to make a mistake, one will opt not to do anything at all instead.
Could be just me, though.
Here’s an article from ISMP prior to the incident in question.
https://www.ismp.org/resources/paralyzed-mistakes-reassess-safety-neuromuscular-blockers-your-facility
The risks were not unknown. They were known by many administrators in many places. There were studies and articles written about these high risk medications. But instead of addressing the risks and safety protocols, hospital administrators have instead elected to wait until a sentinel event to address them.
As is another saying in medicine: nothing changes until someone sues or someone dies (sometimes both).
For the people who act like the medications all looked so different, look at this picture:
This was the packaging in 2016.
And if you click on the link it will tell you this story:
Good thing the patient lived, because there were no criminal charges made. In the first case, however, we do not hear about the outcome. I would give strong odds that the patient arrested there as well, since opiate overdose already causes respiratory depression and vecuronium causes total paralysis.
If we went by @Arizonapatriot ‘s exacting standards, the pharmacist would have been charged, the nurse would have been charged and then the ICU nurse in the second case would have been charged as well. They were grossly negligent for misreading and dispensing such dangerous drugs and then for administering them with an assumption that they knew their generics from their brand names.
And then there is the whole issue of changing drug companies. Things that used to be in ampules are now in vials and vice versus. The pharmacy sends up things in the tube station because you don’t have it in your Pyxis and you have to reconstitute it where before it was in a mini-bag. This doesn’t look the same as it did when I hung it yesterday? etc. etc. I know y’all don’t want to hear it, but it’s a miracle more things don’t happen. I just left a nurse’s retirement party and heard things that made me soooo glad I’m not working anymore.
3-electronic systems do have too many alerts & overrides- it seems like they are made by a committee of people who never have to actually use the system at the bedside-but if she had to override 5 times that is either inattention by her or a really bad system. Override & alarm fatigue is, at times, a real issue.
4-not an issue- she was unlikely to need monitoring and I doubt it would have helped much unless they brought resuscitation gear on transportation to radiology & they were skilled in using it (but since she was near discharge they probably only transported her by an orderly). The paralytic would kick in probably while rolling down the hall or in an elevator & they no doubt missed the signs (you don’t need a sophisticated monitor to notice the patient looks like a fish flopping on the beach)- people weak from a small dose of paralytic typically raise a stink before they code ( a big dose shortens the commotion). The doctor had no reason to order a monitor but Vandy should have mandated monitoring if a sedative is given.
8- has no bearing on why the catastrophic medication error occurred.
9-same as above- plus it looks like Vandy has some problems. Some of the errors are “never-nevers” for CMS and will get you in real problems with Medicare.
10-true- but it doesn’t obviate the problem- it is the problem.
criminalizing the error is excessive unless they had strong evidence of a very cavalier disregard for safety by the nurse. Not having much of the details makes it hard to opine from a distance.
unremarked issues –
a) time pressure- did she have an excessive patient load to care for or unreasonable supervisory duties?
b) almost all serious errors have a number of slip ups that align to allow the safety system to fail. Putting all the blame on one won’t prevent a recurrence unless there was gross & cavalier negligence. Vandy needs to seriously assess the failure- hopefully they already have.
So a jury verdict has been rendered. Juries get it wrong sometimes: Mr. Simpson got away with murder, after all. I am neither a legal expert nor a medical expert, and I’m unfamiliar with details of the case that might change my opinion about it. Based on what I’ve read, I think removing the woman from the nursing profession would have been a reasonable minimum consequence, and that a sentence of twelve years in prison seems excessive. Somewhere between those extremes, and much closer to the non-punitive end of the spectrum, seems more appropriate to me.
Scapegoat? Perhaps. But a scapegoat serves a function, which is to carry the guilt so that someone else is saved from doing so. Is she serving that function in this case? That is, is her prosecution somehow sparing the hospital from scrutiny it may well warrant and may yet receive? If not, then scapegoat isn’t quite right: it’s unlikely she’s been thrown to the wolves by the institution if her punishment will not spare the institution its day of reconning.
Is it possible that, rather than a scapegoat, she’s serving as an example? I’ve read much here about the failures of the institution, failures at all sorts of levels and by all sorts of people. The truth is, unfortunately, that hers was the first and essential failure, the one that started it all and that was wholly the result of negligence in executing a basic function. Could someone have decided that it was time to stop allowing this kind of negligence to be treated as an acceptable — in some sense — consequence of business as usual?
As a potential (though, thankfully, not yet an actual) consumer of hospital care, I’m unsettled by the fact that an innocent woman was killed because of what are alleged to be systemic institutional failures, and that the event was, not quite but almost, swept under the carpet by the institution at which it occurred. Had the event been the result merely of one incautious nurse, I think her dismissal would have been adequate. But we’re apparently being told that in the context of her workplace and situation this tragedy is not as grossly negligent, not as inexplicable, as one might at first believe. If that’s true, it suggests that something is seriously broken at Vanderbilt, and perhaps in health care in general. (Spoiler: yes, something is seriously broken.)
A reasonable question to ask, in that case, might be: are we dragging enough people into court, given the dangerous environment which the medical profession seems willing to create and tolerate?
As I said, I think the punishment for Ms. Vaught is excessive, though I’d stop short of saying that any criminal prosecution is excessive. But as a potential consumer of hospital services, I’m less interested in excuses and more interested in seeing the status quo change.
Disagree. The first failure was at least the medication dispensing situation that was not right. And which had been not right for a considerable period of time before this one event. Although that might still not be the FIRST failure, if you consider the first failure to be understaffing, overworking, etc.
No, I’m going to disagree with that. She understood the environment within which she was working, and she knew why the override feature existed and the risks associated with it. If all the drugs had been stored in a single cabinet and she had taken down the wrong bottle, the failure would be similar. She administered the wrong drug despite ample indicators that she was making a mistake — indicators she ignored through what she admits was her own complacency.
I don’t think her mistakes excuse the mistakes that made her mistakes possible, and apparently – for some odd reason – even somehow uncorrectable. As TRN mentioned, most other hospitals have counter-checks in place for these very reasons. Vaught’s didn’t, either through administrative complacency, or ignorance, or unwillingness to spend what it took to be safer…
There weren’t any. O.J. was acquitted by a jury that couldn’t spell DNA.
I suppose that will always be a defense: if this-or-that safety feature had been in place, I probably wouldn’t have made the mistake I made.
I just don’t buy it. If the drug had been in the wrong bottle, or if the machine had dispensed a drug other than the one she requested, then perhaps. She knew how to use it and it did exactly what she asked of it. She overrode the safety mechanism because she made a mistake about the drug name, and then made a second mistake about the drug name, and then administered the wrong drug. There’s a difference between a process that could be better, on the one hand, and a user who uses it incorrectly, on the other. I’ll stand by that assessment.
Damn.
Well, I guess all nurses everywhere during Covid (especially) should’ve just up and quit. After all, they knew the environment in which they were working.
They knew there wasn’t appropriate PPE.
They knew there wasn’t appropriate staffing.
They knew there wasn’t appropriate stock, supply, or medications.
After all, they knew it was trash. They should’ve just refused to work.
This is the exact attitude why nurses are afraid to practice. Thank you for proving the point of overlitigation as precedent.
Heh. I meant change my mind about the Vaught case. OJ was a stone cold killer, and the jury was ignorant and perhaps stupid.
I don’t think that’s a rational response to my comment.
She made a mistake. Did she understand how the machine worked? Did she understand the purpose of the override mechanism, and the risks associated with it? Did she understand that, having activated the override, only her own attention could prevent a fatal mistake?
Yes, I know it’s often hard and unpleasant being a health care worker. But if we’re going to use that as an excuse for killing a woman through negligence then, yes, get out of the business. Refuse to work. Become a whistleblower. Do something that doesn’t carry the responsibility of making life-critical decisions on a daily basis in a stressful environment.
I have little sympathy for people who complain about how awful it is to do the job they do; less still for people who complain about their customers; and vanishingly little for people who accidentally kill people because they weren’t paying attention to what they were doing.
PS Having said all that, I do think she got a raw deal. As did Mrs. Murphey. And I feel sorry for both of them.
I think the point made earlier was that “overrides” were ROUTINE because the system wasn’t operating correctly. An “override” would have been required to get the CORRECT medication too.
I think your response is patronizing at best, most likely to be mansplaining, which is not something I come across frequently on this site. But there’s a first for everything.
You then decided to double down on it by equating my position (that the error likely does not amount to murder, and more specifically that nurses work in less than ideal circumstances regularly) to an irrational response.
Then, you elected to follow it up with if nurses can’t cope with “hard and unpleasant” circumstances, one should “refuse to work” because it is a “stressful environment”.
At the same time that you have indicated that it isn’t all that bad and that my response is irrational, you have also indicated that even if it were, it would be complaining and that nurses could just stop working under bad conditions. And that they somehow should also be capable of “making life-critical decisions on a daily basis in a stressful environment.”
Pick a lane, Racette.
For those of you who want an opinion by a nurse who has a series on the case, but adequately addresses the issue:
This one in particular addresses the “anonymous tip” situation, which was dodgy at best.
Apparently not in this case. She entered the first two letters for the wrong name for the drug she wanted, a trade name rather than the generic name under which it was filed. When that didn’t give her the drug she wanted, then she overrode the safeties.
She then typed the same wrong letters, but this time it happened to match another drug.
In other words, she overrode the system because she made a mistake, not because she had to, and then made a further series of mistakes after performing the override. And, as she later acknowledged, there was no emergency that justified the override.
I was shooting for mansplaining, so let’s go with that.
No. I suggested that your reply #72 was not a rational response to what I wrote. What I wrote (#68).
I had claimed that she made the first mistake, by dispensing the wrong drug through her own carelessness.
FlickKE replied that, no, the first failure was that the medical dispensing system was “not right,” and perhaps other failures even preceded that.I disagreed, pointing out that the she understood the function of the machine and the machine functioned as intended. It gave her the drug she requested. She understood the operation of the machine, the danger of the override feature, etc. The machine worked correctly. It might not be a good machine, but it wasn’t in error. The nurse was in error.
Your response, RN, was about COVID, PPE, staffing, and I guess a generally unpleasant work environment. Whatever it was, it didn’t address the point I’d made, which is that the error was hers, not the machines.
I don’t think we should blame her mistake on COVID, lack of masks, cranky patient families, short staffing, supply shortages, or a machine. She made a mistake while preparing drugs to be injected into a patient. She made a mistake in a drug name, turned off the safety features rather than pause to understand her mistake, repeated her mistake, and killed a patient.
Nothing to do with COVID, PPE, etc.
Except, The way it’s been described earlier/elsewhere, entering the CORRECT two letters would not have avoided the need for an override, because the system wasn’t set up/operating correctly. Which means that overrides became common as a compensation/workaround, and so needing to override would not automatically be seen as such an important event as it should be.
I haven’t seen that, and I’m skeptical. But if I read somewhere that entering MI would not have brought up the appropriate drug, miazolam, then I’ll take that into consideration.
Or even if it had, that an override might still have been required because the system wasn’t working properly.
I hope you’re not referring to me. All I’ve said on this whole thread was just add water.
I have seen nothing to suggest that, had she used the system correctly, it wouldn’t have given her the drug she wanted. I’m open to the possibility that it might not, but I need some evidence of such a gross malfunction in order to believe it.
My error. All you pseudonymous guys (?) look the same to me. Sorry. I’ll fix it. ;)
The point is also that, even if it hadn’t required an override in that one instance, overrides were required often enough – because the system wasn’t working like it should have – that having to override lost significance.
But do you see how we’re now creeping into well-the-machine-isn’t-perfect-so-it-isn’t-my-fault territory.
I mean, think about it. Suppose they had to run the override every single time they used the machine. In that case, the machine would be the equivalent of a slow medicine cabinet. And her mistake would have been to take down the wrong bottle, not look at the label, prepare the injection, and kill the patient.
The fact remains that they know that, once they hit override, they can dispense anything, including a fatal dose of a paralytic drug. I’m sure she knew that.
Nurses should be encouraged to pause and focus on the drug they’re about to inject into a patient. I know I’d want that as a patient. Perhaps now a few nurses will be more careful than they might otherwise have been. And yes, I know it’s a terrible price for Ms. Vaught to pay for a terrible mistake, and probably worse than she deserves. (I think so, anyway.)
Or guys named Henry or Hank. :)
By the way, I don’t like playing the heavy here. I really do feel sorry for Ms. Vaught. I think the punishment — if it really is a 12 year sentence — is far more than seems appropriate for what was undoubtedly a tragic mistake.
But the prosecution isn’t here on Ricochet to make their case, and we do have a dead woman who might be alive today if Ms. Vaught had been more careful in her very serious duties. That’s a big deal, and I get uncomfortable when the focus seems to be too little on the patients’ side, and perhaps overly concerned with the chilling effect this might have on people in the medical profession.
Stuff like this has a chilling effect on those of us in the patient profession, too.
As a computer user, as opposed to a programmer (which I think may make a difference) computers come up with warning and urgent screens all the time, in exactly the same places. After a while you just expect them and ignore them — because it takes time to reread the same warning you’ve clicked through a thousand times before. I mentioned this to a guy who was conducting training on a particular program, and he just stared at me in shock and dismay. But it’s real to anyone who actually uses the programs.