The story of former Vanderbilt nurse RaDonda Vaught should be a wake-up call for health system leaders, according to patient safety advocates. That’s because the former nurse was prosecuted for a fatal medical error that was caused by systemic problems at the hospital she worked at.
Her criminal conviction has set off a national conversation about nursing shortages and patient safety. On Friday, Vaught was sentenced to three years of probation and judicial diversion.
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What Happened?
During the trial of RaDonda Vaught, hundreds of nurses across the country rallied in support. Wearing purple t-shirts, they gathered outside the Davidson County Criminal Courthouse in Nashville to call for protection from being prosecuted for mistakes made while working in hospitals.
Vaught had been employed as a “help all” nurse at Vanderbilt University Medical Center in late 2017 and was assigned to help Charlene Murphey, 75, get a PET scan. Murphey was claustrophobic and was prescribed the sedative Versed to calm her.
But Vaught overrode the medication cabinet’s automated safety checks and removed vecuronium, an even more powerful paralytic drug, instead. She did not re-check the name on the vial or look at the warnings on the bottle, she says.
Her error killed Charlene Murphey. In addition to her wrongful death charge, which carries a possible sentencing of one to six years in prison, Vaught was found guilty of criminally negligent homicide and gross neglect of an impaired adult.
Why Was She Charged?
A case of medical error that led to a nurse’s criminal indictment has captivated and horrified medical professionals nationwide. The story of RaDonda Vaught, a Tennessee nurse who injected her patient with the wrong medication, has ignited debate about whether health care professionals should be held criminally liable for mistakes.
Until now, most cases of medical error end in civil court with nurses and doctors suing hospitals and nursing home providers for compensation. District attorneys rarely prosecute cases of medical error in criminal courts unless it appears to be overwhelmingly intentional.
A jury found Vaught guilty in March of criminally negligent homicide and abuse of an impaired adult, a charge that could result in three to six years in prison. She will be sentenced Friday by Nashville Criminal Court Judge Jennifer Smith.
What Happened Next?
The story of RaDonda Vaught’s fatal medication error has become a national symbol of the pressures that nurses face in their work. Many worry that her conviction could set a dangerous precedent for criminalizing medical mistakes.
The case against Vaught, which is pending in Nashville, is a rare example of a healthcare worker facing years in prison for a fatal error. Typically, fatal errors are handled by professional licensing boards or civil courts.
Nurses and health care professionals across the country are closely watching this trial to see how it plays out. Some worry that a conviction like this could discourage nurses from sharing their own errors and near-errors with government officials or their peers.
Prosecutors argued that Vaught overlooked multiple warning signs when she grabbed the wrong drug. She also disengaged a safeguard that would have prevented her from using vecuronium, which is a more powerful drug than Versed and needs to be mixed with a liquid.
What Can We Learn From This Case?
The case of RaDonda Vaught, a former nurse at Vanderbilt University Medical Center who wrongly administered the drug vecuronium instead of Versed to a patient in 2017, is a painful reminder that errors do happen. They require no malice or criminal intent, but they can be harmful to patients and caregivers.
In this case, Vaught bypassed at least five warnings in the electronic medication cabinet before she dispensed vecuronium to Charlene Murphey, who died shortly after. She also overrode the safety system that prevents nurses from withdrawing a specific drug without first typing in its generic name.
While criminal prosecutions are rare, they may be the best option in some cases where a medical mistake is especially serious and requires swift action to protect the public. However, prosecutors should consider how their actions will impact nursing, particularly in light of the pandemic and staffing shortages across the country. If nursing is forced to fear criminal prosecution for error disclosure, it will likely drive out more nurses and reduce reporting of errors, thereby depriving hospitals of the opportunity to improve patient safety and reduce errors.
