Fatal Mistake

RaDonda Vaught stood in silence next to her attorney, seemingly resigned to her fate as the jury rendered its verdict. Guilty of gross neglect of an impaired adult. Guilty of criminally negligent homicide. The charges stemmed from a fatal medication error Ms. Vaught committed while working as a nurse at Vanderbilt University Medical Center (VUMC) in Nashville on Dec. 26, 2017. The patient, 75-year-old Charlene Murphey, was being treated for a brain injury when Ms. Vaught accidentally administered the powerful neuromuscular blocker vecuronium instead of the sedative Versed (midazolam), which Ms. Murphey was prescribed to calm her nerves before entering an MRI machine. She died a day later. VUMC fired Ms. Vaught  on Jan. 3, 2018, reportedly for not following the “five rights” of medication administration.

During a hearing in front of the Tennessee Department of Health in July 2021, she said upgrades to VUMC’s electronic medical record led to delays in medication orders reaching the hospital’s automated drug dispensing units. She claims VUMC’s staff was told to use override modes in the units in order to access medications in a timely manner. “Overriding was something we did as part of our everyday practice,” said Ms. Vaught. “You couldn’t get a bag of fluid for a patient without using an override function.” A spokesman for VUMC did not respond to a request for comment.

Still, Ms. Vaught takes full responsibility for her actions. In court documents, she admitted it struck her as odd that she had to reconstitute the powdered vecuronium with saline solution when Versed comes in liquid form. She looked at the back of the vial she pulled for directions on how to reconstitute the drug it contained, but admitted to never checking the name of the medication on the front of the container. Ms. Vaught admitted to being distracted by talking to a coworker while dispensing the medication and said she should have paid closer attention to the task at hand. 

The Tennessee District Attorney’s Office took the unusual step of pursuing criminal charges. During Ms. Vaught’s trial, the prosecution convinced the jury that she was negligent in administering the wrong medication. “This case is not about the nursing profession or the healthcare community,” says Steve Haslip, spokesman for the DA’s office. “This case is about the single individual who made egregious actions and inactions that killed an elderly woman. The jury, which included a long-time nurse and another healthcare professional, found Ms. Vaught’s actions so far below the protocols and standard level of care that they returned a guilty verdict in less than four hours.”

Ms. Vaughn’s sentence, scheduled to be imposed on May 13, could include jail time. Peter Strianse, her attorney, said the on-the-job mistake shouldn’t be criminalized and claimed ongoing issues involving the automated medication dispensing units at VUMC contributed to the error. In published reports, Mr. Strianse said his client was scapegoated to protect the reputation of VUMC. He did not respond to a request for comment for this article.

During the Tennessee Department of Health hearing, after which Ms. Vaught lost her nursing license, a member of the panel asked a simple and profound question: Why didn’t you read the label before administering the medication? Ms. Vaught paused before answering. “There’s no good answer,” she said. “There’s a list of things I could come up with — being distracted, thinking about other tasks, having a conversation while pulling medications — that in hindsight were not appropriate.”

Months later and minutes before entering a Nashville courtroom to learn her fate, Ms. Vaught told a Tennessean reporter that she had “zero regrets” about telling the truth. “We have not forgotten about Ms. Murphey and her family,” she said. “Not at all. Not at all. This is about creating a safer environment so that things like this don’t happen again.”

Is Ms. Vaught the victim of a broken system? Is she a careless provider whose actions led to a patient’s death? Should human errors be prosecuted in criminal courts or handled by licensing boards and civil lawsuits? Many healthcare workers who are discussing these issues on social media and in breakrooms across the country are asking themselves a more urgent question: Could this happen to me? 

The trial sparked a visceral and ultimately career-altering reaction in Debbie Shilobod, RN. “I watched the expert witness, a nurse who hadn’t even practiced recently, and the prosecution just slamming [Ms. Vaught],” she says. “I put myself in her shoes and thought, ‘This could happen to any one of us.’”

Ms. Shilobod has worked in health care for four decades and says being a nurse is her identity. She had planned to work seven more years until retiring, but the Vaught ruling changed those plans. She feels like she now has no choice but to end her career earlier than expected.

Ms. Shilobod, who was once disciplined for an honest medication error in which the patient survived, says the Vaught verdict will make it difficult to encourage the reporting of errors and near-misses in order to learn from the mistakes and prevent repeating them in the future. She believes the Vaught verdict sets a terrifying precedent for all nurses — particularly surgical nurses who are often pressured to expedite cases. “We take a lot of verbal orders during procedures,” says Ms. Shilobod, who has worked in the ambulatory surgery field for the past six years. “The circulating nurse is often ordered by a surgeon to administer a medication at the sterile field during the procedure.”

How can the healthcare system respond to a ruling that potentially opens the door for well-intentioned nurses to face negligent homicide charges when a mistake is made? The verdict, according to Ms. Shilobod, has given the legal system a license to prosecute nurses, and that will ultimately make health care less safe for patients. “Nurses will be extremely hesitant to follow the correct reporting process if any type of error is made,” she says.

Rebecca Gibson, BSN, RN, had just completed a travel nursing assignment and was getting ready to sign a new contract when the verdict was handed down. Ms. Gibson, who is pregnant and due in August, says the case not only prompted her to take an early maternity leave, but also led to her decision to leave the profession of nursing altogether. “My husband and I decided it was best to leave the bedside,” she says. “Working as a nurse right now is scary, and it was a stress I needed to remove from my life.”

This could happen to any of us. Just culture is dead.
— Debbie Shilobod, RN

Ms. Gibson is worried about what the future holds for the profession. “A ‘just culture’ is one that encourages the reporting of errors and near-misses in order to learn from mistakes and prevent repeating them in the future,” she says. “How many nurses will second guess self-reporting after this verdict? How many will shy away from participating in a just culture because they’re afraid of facing legal prosecution for a mistake?”

Ms. Shilobod puts it more bluntly. “Just culture is dead,” she says.

Ms. Vaught broke down in tears during the Tennessee Department of Health hearing in July. “I know the reason this patient is no longer here is because of me,” she said. “There won’t ever be a day that goes by that I don’t think about what I did and how it’s affected her family.”

At the time, Ms. Vaught said fellow nurses and healthcare professionals have been very kind and offered their support — many of them telling her that they could have made the same mistake.

“This has served as a daily reminder of how important it is to consider that patient safety should always come first,” she said during the hearing. “The risks nurses take are much higher than they are in other careers, and that means we have to be more responsible.

“There are a lot of emotions I’ll carry with me for a very long time, but at the end of the day my life won’t ever be the same,” she continued. “The only thing I can ask is that hopefully what happened to me leads to changes that make our processes better.” OSM