Mark Humphrey / AP
Four years ago, inside the most prestigious hospital in Tennessee, nurse RaDonda Vaught withdrew a vial from an electronic medicine cabinet, administered the drug to a patient, and somehow overlooked signs of a terrible and deadly mistake.
The patient had to have Versed, a sedative that was supposed to calm her down before she was scanned in a large, MRI-like machine. But Vaught accidentally grabbed hold of vecuronium, a powerful paralyser that stopped the patient’s breathing and caused her brain death before the defect was discovered.
Vaught, 38, admitted her mistake at a hearing in the Tennessee Board of Nursing last year, saying she was “satisfied” with her job and “distracted” by an intern while operating the computerized medicine cabinet. She did not abdicate responsibility for the mistake, but she said the blame was not hers alone.
“I know the reason this patient is no longer here is because of me,” Vaught said, beginning to cry. “There will never be a day that I do not think about what I did.”
If Vaught’s story had followed the path of most medical errors, it would have been over hours later when the Tennessee Board of Nursing revoked her license and almost certainly ended her nursing career.
But Vaught’s case is different: This week, she faces a lawsuit in Nashville accused of ruthless murder and aggravated assault of a debilitated adult for the murder of Charlene Murphey, the 75-year-old patient who died at Vanderbilt University Medical Center at the end of December 2017. If Vaught is convicted of ruthless murder, he risks up to 12 years in prison.
Prosecutors do not claim in their trials that Vaught intended to injure Murphey or had been weakened by any drug when she committed the mistake, so her prosecution is a rare example of a health worker risking several years in prison for a medical error. Fatal errors are generally handled by licensing boards and civil courts. And experts say prosecution like Vaught’s tissue is great for a profession that fears the criminalization of such errors – especially because her case depends on an automated drug delivery system that many nurses use every day.
The Nashville District Attorney’s Office declined to discuss Vaught’s trial. Vaught’s lawyer, Peter Strianse, did not respond to requests for comment. Vanderbilt University Medical Center has repeatedly declined to comment on Vaught’s trial or its procedures.
Vaught’s trial will be overseen by nurses across the country, many of whom worry that a verdict could set a precedent – as the coronavirus pandemic leaves countless nurses exhausted, demoralized and likely more likely to fail.
Janie Harvey Garner, and St. Louis registered nurse and founder of Show Me Your Stethoscope, a nursing group with more than 600,000 members on Facebook, said the group has been following Vaught’s case closely for years of concern for her fate – and their own.
Garner said most nurses know all too well the pressures that contribute to such a mistake: long hours, overcrowded hospitals, imperfect protocols, and the inevitable creep of complacency in a job with daily efforts at life or death.
Garner said she once switched powerful medications, just like Vaught did, and only caught her mistake in a last-minute triple-check.
“In response to a story like this, there are two kinds of nurses,” Garner said. “You have the nurses who assume they would never make such a mistake, and usually it’s because they do not realize they could. And the other kind are those who know it can happen, which any day, no matter how careful they are. It could be me. I could be RaDonda. “
As the trial begins, Nashville’s prosecutors will argue that Vaught’s mistake was anything but a common mistake that any nurse could make. Prosecutors will say she ignored a cascade of warnings that led to the fatal error.
The case depends on the nurse’s use of an electronic medicine cabinet, a computer-controlled device that dispenses a variety of substances. According to documents filed in the case, Vaught initially tried to withdraw Versed from a cabinet by typing “VE” in its search function without realizing that she should have been looking for its generic name, midazolam. When the cabinet did not produce Versed, Vaught triggered an override that unlocked a much larger selection of drugs, and then searched for “VE” again. This time, the closet offered vecuronium.
Vaught then ignored or circumvented at least five warnings or pop-ups that said she was withdrawing a paralyzing medication, documents show. She also did not acknowledge that Versed is a liquid, but vecuronium is a powder to be mixed into liquid, documents say.
Finally, just before she injected vecuronium, Vaught inserted a syringe into the vial, which would have required her to “look directly” at a bottle cap that read “Warning: Paralyzing Agent,” according to DA documents.
The DA’s office points to this disregard as central to Vaught’s ruthless murder charge. Vaught admits that she committed a breach of the Cabinet. But she and others say overrides are a normal surgical procedure used daily in hospitals.
While testifying before the Nursing Council last year and announcing her defense in the upcoming trial, Vaught said that at the time of Murphy’s death, Vanderbilt instructed nurses to use overrides to overcome cabinet delays and constant technical problems caused by an ongoing overhaul of the hospital’s electronic medical record system.
Murphey’s care alone required at least 20 cabinet overruns in just three days, Vaught said.
“Override was something we did as part of our practice every day,” Vaught said. “You could not get a bag of fluid for a patient without using an override function.”
Violations are also common outside Vanderbilt, according to experts following Vaught’s case.
Michael Cohen, emeritus president of the Institute for Safe Medication Practices, and Lorie Brown, former president of the American Association of Nurse Attorneys, each said it is common for nurses to use a waiver to get medication in a hospital.
But Cohen and Brown stressed that even with a breach, access to vecuronium should not have been so easy.
“This is a drug that you should never ever be able to override,” Brown said. “It’s probably the most dangerous medicine out there.”
Cohen said that in response to Vaught’s case, manufacturers of medicine cabinets modified the software of the devices to require up to five letters to be entered when searching for drugs during a breach, but not all hospitals have implemented this protection. Two years after Vaught’s mistake, Cohen’s organization documented a “strikingly similar” incident in which another nurse swapped Versed for another drug, verapamil, while using an override and searching with only the first few letters. That incident did not result in a patient’s death or prosecution, Cohen said.
Maureen Shawn Kennedy, editor-in-chief emerita for American Journal of Nursingwrote in 2019 that Vaught’s case was “every nurse’s nightmare.”
In the pandemic, she said, this is more true than ever.
“We know that the more patients a nurse has, the more room there is for error,” Kennedy said. “We know that when nurses work longer shifts, there is more room for error. So I think nurses get very worried because they know it could be them.”
KHN (Kaiser Health News) is a national newsroom that produces in-depth journalism on health issues. It is an editorially independent operating program for KFF (Kaiser Family Foundation).