In 2012, RaDonda Leanne Vaught, 28, enrolled in Western Kentucky University, majoring in Nursing. In 2015, she made the dean’s list, passed her nursing board exams, and began her career as a registered nurse at the prestigious Vanderbilt University Medical Center (VUMC) in Nashville, TN. RaDonda had no medical discipline on her record – until December 2017.
Charlene Murphey was born and raised in the Gallatin area of Tennessee. She worked at Walmart for 24 years before having to retire due to health issues. She and her husband, Sam, were married for over 50 years at the time of her death.
Ms. Murphy was suffering from headaches and loss of vision in her left eye when she was admitted to the intensive care unit at VUMC. An MRI evaluation discovered that she was suffering from a subdermal hematoma – a buildup of blood between the brain and the skull causing pressure on the brain. This is usually caused by a head injury but that history was not reported. After a few days in the hospital, Ms. Murphy was feeling better. One last test was to be done prior to her discharge – a Positron emission tomography (PET) scan to evaluate her condition.
On December 26, 2017, Ms. Murphy, who suffered from claustrophobia, requested medication to help her relax during the upcoming scan. Her physician was contacted and an order for intravenous Versed (midazolam) was provided. The nurse in the radiology department where the PET scan would be done was uncomfortable with administering Versed and asked if the patient’s primary nurse could do it. Medications are usually provided by a patient’s primary nurse, but since she was busy with other patients, she asked a “floater” nurse, RaDonda, to go to the radiology department to administer the drug to Ms. Murphy. RaDonda was orienting a new nurse and was on her way to the Emergency Department (ED) to conduct a swallowing test on a patient there. But she agreed to go to Radiology and administer the medication to Ms. Murphy first.
In order to provide medications in UVMC, as in many hospitals, nurses must retrieve the medication from a mobile unit that is stocked by the hospital’s pharmacy. The nurse enters the first two letters of the drug and a drawer containing that medication will open. On that day, RaDonda entered “VE” but no drawer opened. She then used an override that included a wider range of medications. The drawer that opened contained a medication whose first letters were “VE”, but RaDonda did not recognize that the drug was Vecuronium – not Versed. And that was the start of the medication error.
The Institute for Safe Medication Practices (ISMP) reports that this type of error could happen anywhere given current system vulnerabilities frequently found in hospitals, particularly when using automated dispensing cabinets like the one RaDonda used at UVMC. Technical issues hamper accurate medicine retrieval from the mobile units in many hospitals; overrides are commonly used.
RaDonda removed the vial which clearly stated, “Warning: Paralyzing Agent,” and reconstituted the powdered medication with saline, a step not required in the administration of Versed which is a liquid. The ISMP reports that RaDonda was not the first person to overlook or misunderstand the warning sticker on the vial. She administered the medication into Ms. Murphey’s intravenous line, collected her things and proceeded to the ED to perform the swallowing study.
There is some confusion in the published record as to who was responsible to monitor Ms. Murphey after she received what was thought to be Versed, who discovered she was not just relaxed but was unconscious and not breathing, and where she was at the time – in the PET scan or in a holding room. Regardless, about ½ hour after the injection, someone noticed that Ms. Murphey was not merely relaxed, she was unconscious and not breathing. A code was called and the medical team was successful in restoring circulation, however she required a ventilator to breathe and was returned to the intensive care unit.
RaDonda responded to the code too, knowing she had recently been in Radiology. She reviewed the steps she had taken earlier and retrieved the syringes she had used and labeled – and that’s when the medication error was discovered. RaDonda immediately owned her error and reported it to the code team and to her nursing supervisor.
Unfortunately for all of us, medication errors are very common. They occur in the hospital, in the doctor’s office, and in the home. Approximately 8,000 Americans die each year as a result of a medication error – a rate of about one death every day in the U.S. They are estimated to be between the 3rd and the 8th leading cause of death in the U.S., depending on what source documents and methodologies researchers use to estimate the rate. It is not a U.S.-based phenomenon – the World Health Organization has launched a global program to reduce medication-associated harms by 50% over the next 5 years.[ii] Causes include errors by clinicians, pharmacists, and patients, poor communications, technological errors, and counterfeit drugs, among others.
Having not heard from Ms. Murphy for some time and not able to receive an update to her condition, the family began pressuring Vanderbilt staff to tell them what was going on. Eventually, a doctor called and told the family that Ms. Murphey was in critical condition and recommended they come to the hospital. The medication error was admitted to the family and they were told that she had suffered severe brain damage during the period when she was not breathing – only the ventilator was keeping her alive.
Ms. Murphey’s son, Gary, said that his mother was the kind of person who would have forgiven the nurse who made the error and that the family had no intention of pursuing legal action against the hospital. Nonetheless, a financial settlement (which prohibited the family from speaking publicly about the incident) was provided to the family.
VUMC is a highly acclaimed teaching hospitalin Nashville, TN. It was recently the only health system in the Southeast to be named to the U.S. News & World Report’s Honor Roll of America’s Best Hospitals. Their reputation is stellar – and well protected, it seems.
On December 27, 2017, two neurologists reported the death of Charlene Murphy to the Davidson County Medical Examiner’s Office, noting the cause of death as “natural” and due to a brain bleed (the original reason for her hospital admission). However, they did not report the fatal medication error to state or federal regulators as is required by law.
One week after the incident, on January 3, 2018, UVMC fired RaDonda Vaught for errors in medication administration. On October 23, 2018, following a review of her case at which she had testified truthfully about her error, the Tennessee Board of Nursing sent a letter to RaDonda reporting that, following their review of events, they have made the decision not to pursue disciplinary action against her. A copy was also sent to VUMC.
Meanwhile on October 3, 2018, an anonymous whistleblower notified state and federal agencies about the fatal medication error that occurred on December 26, 2017 at UVMC. The Centers for Medicare and Medicaid Services (CMS) conducted a surprise inspection of VUMC policies, protocols and practices that could have impacted the medication error that killed Ms. Charlene Murphy. VUMC was found to be negligent in this area and was ordered to create a Plan of Correction to address areas of deficiencies with specific actions in order to continue receiving payments for patient care from CMS. The hospital complied, with a rejoinder that “…this plan of Correction does not constitute admission or agreement by the Hospital of the truth of the facts alleged or conclusions set forth in this statement of deficiencies. The Plan of Corrections is prepared and/or executed because it is required by the provisions of federal law” – rather than to improve patient safety?
In January of 2019, after the CMS inspection, the Tennessee Bureau of Investigation, the state’s Department of Health and the Nashville district attorney’s office met. They determined that UVMC “carried a heavy burden of responsibility in this matter.” However, UVMC received no disciplinary sanctions despite identified flaws in its policies and procedures, it’s illegal decision to not report the fatal medication error, and its flawed medication distribution system.
Following the meeting, the Tennessee Board of Nursing reversed its initial decision and revoked RaDonda’s nursing license, fined her $3000 and stipulated that she pay up to $60,000 in prosecution costs. And RaDonda was indicted, arrested, and charged with criminal reckless homicide.
On March 2022, a criminal trial brought by the Nashville District Attorney’s office was conducted. The prosecution used RaDonda’s testimony to the Tennessee Board of Nursing against her, equating her truthful reporting and regret-filled self-blame with a lack of care. In an article titled “A Travesty of Justice that Threatens Patient Safety,” ISMP criticized the prosecution’s “mocking contempt” of RaDonda as they falsely portrayed her actions as “knowingly harming her patient.”
RaDonda Leanne Vaught became the first nurse criminally convicted for a medication error. The jury found her guilty of felony neglect and negligent homicide, charges that could result in 3 to 6 years and 1 to 2 years, respectively. She is currently out on bond.
Many people believe that while RaDonda ignored some serious red flags in her administration of the drug to Ms. Murphy, she had nothing but good intentions and that multiple system failures at the hospital also contributed to the patient’s death. These include the routine overrides necessary to acquire patient medications, inadequate control of dangerous drugs by the hospital pharmacy, and lack of clarity in protocols of patient monitoring responsibilities. There are questions about why VUMC was not also charged for these systemic problems in addition to their dishonest and illegal reporting that the death occurred “naturally,” circumventing an investigation of the incident and resulting in a false cause of death on the patient’s death certificate. Some people have characterized RaDonda as a scapegoat for VUMC that will prevent tarnish to the hospital’s good name and reputation.
The American Nurses Association said, “We are deeply distressed by this verdict and the harmful ramifications of criminalizing the honest reporting of mistakes. Health care delivery is highly complex. It is inevitable that mistakes will happen, and systems will fail. It is completely unrealistic to think otherwise. The criminalization of medical errors is unnerving, and this verdict sets into motion a dangerous precedent. There are more effective and just mechanisms to examine errors, establish system improvements and take corrective action. The non-intentional acts of individual nurses like RaDonda Vaught should not be criminalized…”
Over 100,000 signatures, mainly from health care providers, have been collected on a petition for clemency to the governor of Tennessee. The impact of the first-ever criminal charges for a medication error by a nurse may have a chilling effect on the profession. Many suspect that this outcome will directly cause the resignation of additional nurses who are already reeling from the hits to the profession caused by the COVID-19 epidemic. Others believe that 20 years of effort to build a health care environment that supports the reporting of medical and medication errors that have led to increased patient safety and trust will collapse. Will health care providers feel safe to admit errors if they will then be at risk of criminal prosecution? That jury is still out.
RaDonda Vaught’s sentencing hearing is scheduled for May 13th, 2022.