Former nurse found guilty in accidental injection death of 75-year-old patient

Where do we go from here? What precedent of criminalizing medical mistakes?

Source: https://www.npr.org/sections/health-shots/2022/03/25/1088902487/former-nurse-found-guilty-in-accidental-injection-death-of-75-year-old-patient

RaDonda Vaught, a former nurse criminally prosecuted for a fatal drug error in 2017, was convicted of gross neglect of an impaired adult and negligent homicide on Friday after a three-day trial in Nashville, Tenn., that gripped nurses across the country.

Vaught faces three to six years in prison for neglect and one to two years for negligent homicide as a defendant with no prior convictions, according to sentencing guidelines provided by the Nashville district attorney's office. Vaught is scheduled to be sentenced May 13, and her sentences are likely to run concurrently, said the district attorney's spokesperson, Steve Hayslip.

Vaught was acquitted of reckless homicide. Criminally negligent homicide was a lesser charge included under reckless homicide.

I really don't know how to feel about this and I promised you that I would follow it.

Here is the back story: Vaught is on trial for the death of Charlene Murphey, a 75-year-old Vanderbilt patient who died on Dec. 27, 2017, after she was prescribed a sedative, Versed, but was inadvertently injected with a powerful paralyzer, vecuronium. Vaught does not deny she accidentally confused the drugs but has pleaded not guilty to all charges. Her trial — a rare example of a health care professional facing prison for a medical error — has been closely watched by nurses across the U.S., who worry it could set a precedent for future prosecutions.

In the wake of Murphey's death, Vanderbilt took several actions that resulted in the medication error not being disclosed to the government or the public, according to county, state and federal records related to the death. Vanderbilt did not report the error to state or federal regulators as required by law, a federal investigation report states. The hospital told the local medical examiner's office that Murphey died of "natural" causes, with no mention of vecuronium, according to Murphey's death certificate and Davidson County's chief medical examiner, Dr. Feng Li.

Vanderbilt also fired Vaught and negotiated an out-of-court settlement with Murphey's family that bars them from publicly discussing the death.

Vaught has admitted her role in the fatal drug mix-up, but she insists the error was possible only because of technical problems and flawed procedures in place at Vanderbilt at the time.

The case against Vaught hinges on her use of an electronic medication cabinet, a computerized device that dispenses drugs and is widely used in hospitals. According to documents filed in the case, Vaught initially tried to withdraw Versed from a cabinet by typing "VE" into its search function without realizing she should have been looking for its generic name, midazolam. When the cabinet did not produce Versed, Vaught triggered an override that unlocked a much larger swath of medications and then searched for "VE" again. This time, the cabinet offered vecuronium.

Prosecutors describe this override as a reckless act and a foundation for Vaught's reckless homicide charge. Some experts have said cabinet overrides are a daily event at many hospitals.

Vaught insisted in her testimony before the nursing board last year that overrides were common at Vanderbilt and that a 2017 upgrade to the hospital's electronic health records system was causing rampant delays at medication cabinets. Vaught said Vanderbilt instructed nurses to use overrides to circumvent delays and get medicine as needed.

"Overriding was something we did as part of our practice every day," Vaught testified to the nursing board. "You couldn't get a bag of fluids for a patient without using an override function."

Source: https://www.npr.org/sections/health-shots/2022/03/24/1088397359/in-nurses-trial-witness-says-hospital-bears-heavy-responsibility-for-patient-dea

Vaught faces three to six years in prison for neglect and one to two years for negligent homicide as a defendant with no prior convictions, according to sentencing guidelines provided by the Nashville district attorney's office.

It seems to me that Vanderbilt has a very serious liability in this case and has found a scape goat. While recognizing that Ms. Vaught did indeed make a grave human error, given the stress of the job, understaffing, and the way in which the over rides are used in this facility I think, unfortunately it was bound to happen at some point. In addition Vanderbilt failed to tell the state the correct reason for death (the wrong drug given in error vs. natural causes. Finally, Vanderbilt did not report the error to state or federal regulators as required by law, a federal investigation report states.

Ms. Vaught will be sentenced in May 13, 2022. How will this case effect the many patient families that lose loved ones annually due to medical mistakes? What will it do to the many professional occupations and healthcare as a whole? What will it do to an already critical lack of employee moral in a over burdened post pandemic system? It is a hard call for me.

I have been on the side of grave medical mistakes both personally and with loved ones. If I didn't pass out on October 11th 2020 in the emergency room after a seven hour wait my discharge papers were already written up. The PA and nurse were terrible and ignored everything I tried to tell them, unhooked me from any vitals, said "I was fine" and had I not passed out unconscious I was going home. The cliff notes were I was bleeding internally for seven hours and they never even did a blood draw. If they had they would have seen my red blood cell count at a 2. When I passed out my blood pressure was 70/30 and my bpm was 170 (but I was fine). I woke up to two nurses on each side of me flooding my body with saline and calling a hospitalist to my bedside that changed the entire record that the PA noted (no abdominal pain, and discharge orders). The next morning I was rushed to emergency surgery by a trauma surgeon that saved my life and I woke up the next day in ICU. My stomach had twisted (gastric volvulus) and become ripped off my spleen. I was dying and being discharged. If I could move and reach my phone I would have called 911 because they were absolutely negligent and if discharged I was told I would have died at home if I even woke up. It does beg the question of what would my family want? What would be the right outcome of such blatant malpractice? Why was this nurse and PA so negligent. I was crying, throwing up and the morphine was not touching my pain? It was during Covid-19 protocol so I was alone like many. I was my only advocate but I was dying without exaggeration. I needed 3 transfusions, surgery and a two day stay in ICU and 13 day stay in the hospital.

This is a complex and highly emotional situation. I'd love to get feedback on other peoples thoughts on this. There is a lot of blame to go around but when does it stop? Can someone that lost a loved one to malpractice ever become whole again? Money doesn't bring your loved one back? Will you want that skin; and if it was at the hand of a mistake such as medicine; should the person be held criminally responsible? If Ms. Vaught is sentenced to time in jail is she going to be the "example" to learn from? The "scapegoat" that Vanderbilt fed to the wolves? Will it improve patient care because healthcare providers will be more careful? Will facilities put better quality control on medicine cabinets and technology? Has technology gone too far and created an environment for this type of error? Will state prosecutors have to review old cases? What exactly will prison do except punish Ms. Vaught for human error?

I have the utmost respect for 95 percent of nurses I have ever met. I say it in #notinvainapromisekept, they are the most important part of the patient team. They are the connective tissue between you and your doctor. They lead the patient team.

This is a tough one. Stay tuned.