Nurses do not typically need to pay close attention to criminal courts, but a huge exception emerged in 2022 with a controversial case: State of Tennessee v. RaDonda L. Vaught.
Monitored closely by nurses and medical professionals across the nation, Vaught’s situation spells huge implications for the healthcare sector. These must be carefully studied by nurses and administrators alike.
Keep reading to get the details on the RaDonda Vaught case, including what happened, why Vaught was convicted, and how nurses can protect themselves and their patients from suffering a similar fate.
Contextualizing the RaDonda Vaught Incident
In many ways, the RaDonda Vaught medication error reflects issues dominant across the scope of modern healthcare. This includes widespread systems concerns regarding the dispensing of potentially deadly medications, issues with electronic health records, and the general culture of safety within today’s medical facilities.
Understanding the details of this case is crucial to understanding why similar errors are so persistently common across the healthcare landscape.
Details of the Medication Error
It all began in late 2017, when Charlene Murphey arrived at Vanderbilt University Medical Center. The 75-year-old patient had a history of cancer and was expected to undergo a full-body PET scan. However, because she was anxious about the scan, her physician decided to administer the anti-anxiety medication Versed.
Designated as a “help-all” nurse, RaDonda Vaught was asked to obtain the medication. She initially attempted to secure it from an automatic medication dispensing cabinet but could not find it. As such, she sought a medication override, which was common practice at the time. The result? She obtained a paralytic known as vecuronium, which is typically meant for surgery.
Soon after this was administered, Murphey was found unresponsive. Sadly, she failed to regain consciousness following resuscitation efforts and, due to permanent brain death, she was taken off life support.
The Aftermath of the Incident
As medical staff members tried to resuscitate Murphey, Vaught realized her error. She reported this to physicians and claimed that she had been distracted while administering the medication. An internal investigation followed and Vaught was quickly fired. The Tennessee Board of Nursing followed up with a review of the case, which, at the time, was deemed an accident.
While a civil lawsuit was settled out of court in 2018, this was only the beginning. Following the reporting of this incident to federal authorities (based on an anonymous tip), a criminal investigation was pursued. This led to indictments for multiple felonies, consisting of gross neglect of an impaired adult and even reckless homicide.
Legal Consequences Faced by RaDonda Vaught
Although acquitted of reckless homicide, Vaught was ultimately found guilty of gross neglect and negligent homicide. She was sentenced to three years of supervised probation. The American Nurses Association (ANA) has expressed gratitude that the judge demonstrated leniency rather than pursuing a prison sentence.
The Trial and the Verdict
Vaught’s conviction followed a controversial trial, in which the prosecution portrayed her as equivalent to a drunk driver — or worse. Attorney Chad Jackson explained, “Charlene Murphey is dead because RaDonda Vaught could not bother to pay attention to what she was doing.”
That said, according to Vaught’s attorney, the reality was far more complicated. Yes, Vaught made a mistake, but this was amplified by complications surrounding Vanderbilt’s medication cabinets. Furthermore, testimony from a neurologist suggested that Murphey’s death could potentially be attributed to her brain injury.
Case Publicity and Public Sentiment
The RaDonda Vaught medication error case generated a great deal of publicity, including swift backlash. This included a Change.org petition that received well over 200,000 signatures. Furthermore, several nursing unions and nurse advocacy groups spoke out in support of Vaught. Some nurses even quit in protest, while others advocated on her behalf via social media.
Nursing License Repercussions
Although the initial board review of Vaught’s case prompted no further action, this eventually changed as civil and criminal consequences were sought. As a result, Vaught was not only charged with a crime, but she also lost her nursing license and was forced to pay a fine of $3,000.
Healthcare Official’s Decisions on Punishment
In a surprising reversal of its original decision, Tennessee’s Board of Nursing charged Vaught with several infractions. Such infractions include the neglect of a patient in need of care, the failure to maintain accurate records, and unprofessional conduct.
This represented a unanimous decision from the board, which claimed that Vaught ignored too many red flags when administering the medication that was ultimately responsible for Murphey’s death. Prior to this decision, Vaught had also lost her job with Vanderbilt.
Impact on Vaught’s Professional Standing
A Tennessee judge eventually rejected Vaught’s attempt to appeal the board’s decision to revoke her license, so she was unable to pursue a new trial. She has since taken the opportunity to speak out about her ordeal and to highlight the need for systems solutions to ongoing issues surrounding medication errors.
The Impact of the Case on the Medical Community
The RaDonda Vaught case has sparked fear and outrage in the wider medical community. Nurses worry that if they report medical errors, they will also be subject to harsh repercussions or even criminal penalties. Nurse leaders fear that these concerns will make hiring more difficult and could exacerbate current issues with labor shortages.
How the Case Influenced Medical Hearings
While Vaught’s criminal case has attracted the bulk of the outrage, some of this has also been reserved for Tennessee’s Board of Nursing.
The Institute for Safe Medication Practices (ISMP) called the board’s decision a “travesty on top of tragedy.” They said outcome bias likely influenced the situation, while also noting a lack of attention to system failures and a thorough investigation.
Recent advocacy for the greater presence of nurses on boards of nursing could spur future changes to ensure fairness in future medical hearings.
Nurses’ Reaction to the Case
Nurses agree that the RaDonda Vaught case has forever altered their perception of malpractice. Show Me Your Stethoscope’s Janie Harvey Garner believes that the industry has been irreparably harmed, saying, “You can no longer trust people to tell the truth because they will be incriminating themselves.”
Similarly, an ANA statement expresses concern about the potential for “criminalizing the honest reporting of mistakes,” adding that the ruling is likely to “have a long-lasting negative impact on the profession.”
Reviewing the Hospital’s Role
As RaDonda Vaught’s defense has pointed out, the role of the hospital must be acknowledged. Vaught herself explained, “I do not work in a vacuum. I work in a healthcare system.”
At the time of the incident, there were a wealth of relevant systems concerns at play. Such concerns include issues with the automated medication dispensing cabinets, along with a previously problematic electronic health record (EHR) rollout. These issues contributed to the error and must be addressed.
Hospital’s Response to the Incident
Although EHR and medication dispensing cabinet issues are clearly concerning, Vanderbilt’s most egregious misstep involved its response (or lack thereof) to the incident. Instead of reporting the error, the hospital informed the medical examiner’s office that “natural causes” were responsible for Murphey’s death. What’s more, the hospital used an out-of-court settlement to prevent Murphey’s family from publicly discussing the case.
Evaluating the Hospital’s Accountability
While critics have expressed concern regarding the ease of use for hospital overrides, it is worth mentioning that these overrides exist for a reason, which is to safeguard patients during emergency situations. In the worst-case scenario, nurses can access potentially life-saving medications. Moreover, it can also be argued that safeguards should be established to minimize confusion when accessing these medications and to also prevent nurses from so easily obtaining potentially deadly drugs.
A Nurse’s Role in Protecting Against Future Errors
While far more goes into medication errors than the actions of individual nurses, there is no denying that nurses play a vital role in preventing these potentially tragic concerns. Preventative actions worth taking include:
Stay Alert of Your Surroundings
Situational awareness is a must in registered nursing, as rapidly changing conditions or environmental factors may impact how patients are treated.
Nurses should consistently understand what’s happening around them and why. Additionally, if anything seems out of place, they should be encouraged to report their concerns.
Documenting concerns is important not only from a safety perspective, but also because this forms the basis of a reliable paper trail in the event of suspected malpractice.
Encourage Collaboration and Open Communication
Communication forms the basis of safe nursing practice, and unfortunately, issues with communication and collaboration underscore far too many medication errors. Transparency is a must, including strict administration instructions for both patients and fellow healthcare employees.
Strong communication through “transitions of care” should be top of mind and, while the Agency for Healthcare Research and Quality (AHRQ) refers to these as transfers between settings, similar principles must be in place when nurses ask other nurses to assist with patient care.
Keep the 5 “Rights” in Consideration
The five rights provide a powerful framework for interacting with clients, and sadly, Vaught is believed to have neglected this medication essential. To illustrate, had she confirmed the medication or the reason it was being used, things may have played out differently. To prevent future tragedies, these details must be confirmed when administering medications:
- Right patient
- Right medication
- Right dose
- Right time
- Right route
Communicate Bandwidth
Today’s nurses are expected to juggle a myriad of responsibilities, but there is only so much that any one nurse can realistically handle. Communication can resolve this by ensuring that supervisors are aware of current bandwidth among individual nurses and entire teams or departments. If nurses feel rushed or overworked, supervisors need to be informed so that they can shift responsibilities and caseloads accordingly.
Report Overrides
Dispensing cabinet overrides are currently regarded as standard practice across the healthcare industry, but this is certainly not how these cabinets were designed to be operated. Overrides are supposed to represent a last-ditch option, not a trusted strategy for quickly accessing medications when nurses feel pressured.
IMSP highlights numerous strategies for limiting overrides and emphasizes the need for reporting in the rare situations in which these prove necessary. These reports should be regularly analyzed to verify whether the accuracy of rationales for using override functions.
Safeguard Yourself With Malpractice Insurance
Because medication errors are possible even when nurses abide by best practices, malpractice insurance is crucial. This can provide much-needed financial protection in the event of a lawsuit. Nurses are often advised to maintain personal liability insurance, as hospitals have been accused of throwing healthcare professionals under the bus in the event of legal action.
Lessons Learned From the RaDonda Vaught Case for Hospitals
As nursing advocates have pointed out, Vaught’s case represents far more than the mere negligence of a single nurse. Like Vaught herself, a number of sympathizers believe that a great deal of responsibility lies with Vanderbilt University Medical Center.
It is important to acknowledge that Vanderbilt failed to disclose the fatal drug error and maintained policies that allowed vecuronium to be secured via override in the first place. Add general concerns like staffing issues and production pressures, and it’s easy to see the potential for this tragedy to repeat itself in the future. As such, it is imperative that other facilities and systems learn from Vanderbilt’s oversights.
Identifying Potential Safeguards
While a report in the Journal of the American College of Clinical Pharmacy (JACCP) suggests that just culture, production processes, and system safety concerns played heavily into the RaDonda Vaught case, strong safeguards can limit the necessity for potentially dangerous overrides. Stronger medication requirements could curb the overuse of overrides, along with required documentation in the rare event an override becomes necessary.
Other safeguards could relate to EHR rollouts, as this has been cited as a contributing factor in the RaDonda Vaught medication error. Robust software architecture and governance structures are crucial to ensure that EHR implementation is straightforward and that these transitions do not harm usability.
Implementing Changes in Healthcare Practices
Instead of strictly placing blame on individual nurses for systems-related medication errors, healthcare providers should be open to receiving feedback from nurses. This means encouraging them to share insight about safety concerns without fear of repercussions.
Hospitals should actively seek out nurse feedback and take responses into consideration. If nurses feel that their concerns are taken seriously, they are more likely to abide by safety standards and commit to facilities’ growing safety culture.
How Can Such Incidents Be Prevented in the Future?
In the aftermath of the RaDonda Vaught case, prevention is top of mind for nurses and healthcare providers alike. This begins with addressing systems-level concerns such as ongoing issues with automated medication dispensing cabinets and electronic event reporting systems, both of which sparked concern long before the RaDonda Vaught case entered the national discourse. Enhanced nurse training and communication are also crucial, along with the implementation and maintenance of a strong safety culture.
Is the Medical Community Prepared to Prevent Similar Incidents?
The medical community has been left reeling by the RaDonda Vaught case, but there may be a silver lining to this tragedy. As the Institute for Healthcare Improvement (IHI) points out, this “demonstrates the ever-present need for effective, reliable and resilient systems.” Blaming individuals will not overcome system-level concerns such as problematic EHR integration.
Already, a myriad of healthcare providers have taken actions to boost safety culture while also avoiding technological problems. To note, a Becker’s report indicates that Hackensack Meridian Health now requires staff members to enter five characters (instead of just one) when using automated medication dispensing cabinets.
Furthermore, widespread updates to electronic event reporting systems encourage the reporting of precursor events while limiting clumsy and confusing navigation between multiple electronic systems.
Nurses can play a similarly valuable role in protecting patients. Many have reported a renewed effort to abide by strict safety protocols while fully buying into larger efforts to promote healthcare safety cultures. Training can play a powerful role in this effort and, by committing to higher education, nurses can prepare themselves to tackle the challenges of tomorrow.
Seek High-Level Training to Maintain a High Standard of Care
Don’t let the RaDonda Vaught medication error case stand in the way of progressing your nursing career. If anything, this case reveals the importance of well-trained, passion-driven nurses who can maintain an exceptional standard of care.
If you are ready to expand your nursing skills, look to the Nevada State University RN to BSN program for guidance. Offered online, this program will help you develop critical nursing skills and elevate your practice. Reach out today to learn more.
Sources
https://www.npr.org/sections/health-shots/2022/03/25/1088902487/former-nurse-found-guilty-in-accidental-injection-death-of-75-year-old-patient
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https://www.ncbi.nlm.nih.gov/pmc/articles/PMC9724400/
https://www.ismp.org/resources/over-top-risky-overuse-adc-overrides-removal-drugs-without-order-and-use-non-profiled
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https://www.nursingworld.org/news/news-releases/2022-news-releases/ana-reacts-to-sentencing-of-nurse-radonda-vaught/