In December 2017, a Vanderbilt University Medical Center nurse, RaDonda Vaught, mistakenly administered a wrong medication to a patient. The patient, Charlene Murphey, a 75-year-old woman, died from the medication error. In 2019, Vaught was arrested and charged with reckless homicide and gross neglect of an adult with an impairment. The neglect charge stemmed from allegations that Vaught did not properly monitor Murphey after she was injected with the wrong drug.
In a summary from the National Public Radio (2022), the patient, Murphey, was admitted to Vanderbilt for a brain injury. At the time of the medication error, her condition was improving, and she was being prepared for discharge. She was prescribed Versed to calm her before being scanned for magnetic resonance imaging. Vaught was asked to retrieve Versed from the computerized medication cabinet but instead withdrew vecuronium. Vecuronium is a nondepolarizing steroidal neuromuscular blocker that is often used as an adjunct during general anesthesia to facilitate endotracheal intubation and aid in surgical relaxation (Ramzy & McAllister, 2022). According to an investigative report filed in her court case, Vaught overlooked several warning signs as she withdrew the wrong drug-including that Versed is a liquid but vecuronium is a powder that needs to be mixed-and injected Murphey and left her to be scanned. By the time the error was discovered, Murphey was brain dead.
On March 25, 2022, in a 3-day trial in Davidson County, Tennessee, Vaught was convicted of gross neglect and criminally negligent homicide. She was acquitted of reckless homicide. She will be sentenced on May 13.
One wonders, how did this happen? What went wrong? Nurses everywhere worry that this conviction will cause healthcare professionals to not disclose their own errors. Typically, medical errors are handled by professional licensing boards or civil courts. Criminal prosecutions are rare.
In response to the conviction of former nurse RaDonda Vaught, the American Nurses Association with the Tennessee Nurses Association issued the following statement:
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 in 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 to ensure patient safety.
The nursing profession is already extremely short-staffed, strained and facing immense pressures-an unfortunate multi-year trend that was further exacerbated by the effects of the pandemic. This ruling will have a long-lasting negative impact on the profession.
Like many nurses who have been monitoring this case closely, we were hopeful for a different outcome. It is a sad day for all of those involved and the families impacted by this tragedy. (American Nurses Association, 2022)
There are few nurses who have not committed a medication error sometime during their careers. I remember my first one well. I was a graduate nurse 3 months out of school, had not taken state boards (what we called NCLEX at the time), and was in charge of a 32-bed medical-surgical unit, supported by an LPN and several nursing assistants. It was late in the 3-11 shift, and I was drawing up 10 units of regular insulin for one of the patients. I gave it to the wrong patient. Years later, and it's been 53 years, I remember the error well, including calling the physician and writing up the incident report.
Please read the information about the Vaught case and thoughtfully draw your own conclusions. Unfortunately, the Vaught case is very easy to find online. Put "nurse found guilty" into Google, and immediately, there are multiple sources available. Too bad that putting in "nurse saves lives" produces an initial site with nursing T-shirts.
Each of us will form our own opinion about this case and what is "right" or "wrong." I wish it were that simple. I have thought about this case for some time, and I still don't see a clear answer in one direction or another. You may feel differently.
Postscript. On May 13, 2022, Judge Jennifer Smith granted Vaught a judicial diversion, meaning her conviction will be expunged if she completes a three year probation period successfully.
Conflict of Interest
The author declares no conflict of interest.
Funding
There is no funding associated with this article.
Pamala D. Larsen, PhD, MS, RN
Loveland, CO, USA
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