RaDonda Vaught homicide case

The RaDonda Vaught homicide case was an American legal trial in Nashville, Tennessee in which former Vanderbilt University Medical Center nurse RaDonda Vaught was convicted of criminally negligent homicide and impaired adult abuse after she mistakenly administered the wrong medication that killed a patient in 2017.[1]

The case centered around a nurse who was instructed to administer Versed (midazolam, a sedating drug) but instead administered vecuronium (a paralyzing drug).[2] She tried to withdraw Versed from an automated dispensing cabinet, and when that did not work, she used an override which allowed her access to a larger array of medications.[2] Prosecutors portrayed the use of the override function as evidence of recklessness, even though many experts have testified that overrides are daily events at many hospitals and Vaught stated that Vanderbilt's 2017 upgrade of its computer systems had caused such delays that nurses were instructed to use overrides to prevent delays and get medication that they needed.[2][3] The patient, Charlene Murphey, was a 75 year old woman with a head injury who was to be given Versed prior to an MRI scan, a procedure requiring patients to remain very still for 15 minutes or longer. The incident occurred in December 2017. Ms. Vaught was arrested in 2019.[2]

A Tennessee Bureau of Investigation agent testified at Vaught's trial that the medical center had a "heavy burden of responsibility" for the deadly medication error, but that the Bureau of Investigation only pursued criminal charges and penalties against the nurse, not the hospital.[2] After Murphey's death, the hospital did not report the error to federal or state regulators (as required by law) and reported to the county medical examiner that Murphey died of "natural" causes with no mention of the vecuronium.[2] The hospital also negotiated a out-of-court settlement with Murphey's family which prevents them from disclosing details of her death.[2]

After the verdict, the American Nurses Association (ANA) stated:[4][1]

"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 to ensure patient safety.

The nursing profession is already extremely short-staffed, strained and facing immense pressure – 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."

References
  1. "Former nurse found guilty in accidental injection death of 75-year-old patient". npr.org. Retrieved April 1, 2022.
  2. "In nurse's trial, witness says hospital bears 'heavy' responsibility for patient death". NPR. Retrieved April 1, 2022.
  3. Kelman, Brian (2022-03-22). "As a nurse faces prison for a deadly error, her colleagues worry: Could I be next?". NPR. Murphey's care alone required at least 20 cabinet overrides in just three days, Vaught said. "Overriding was something we did as part of our practice every day," Vaught said. "You couldn't get a bag of fluids for a patient without using an override function." Overrides are common outside of Vanderbilt, too, according to experts following Vaught's case. Michael Cohen, president emeritus of the Institute for Safe Medication Practices, and Lorie Brown, past president of the American Association of Nurse Attorneys, each said it is common for nurses to use an override to obtain medication in a hospital. But Cohen and Brown stressed that even with an override, it should not have been so easy to access vecuronium.
  4. "Statement in Response to the Conviction of Nurse RaDonda Vaught". American Nurses Association. 2022-03-25.
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