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March 23, 2022

'Every nurse's nightmare': How a fatal medical error led to criminal charges

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    After a medication error resulted in a patient's death, a nurse is now on trial for criminal charges, Brett Kelman writes for Kaiser Health News—and nurses nationwide are monitoring the trial since "they know this could be them" next.

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    A medication error results in a patient's death

    In 2017, RaDonda Vaught, a nurse at Vanderbilt University Medical Center, withdrew a vial from an electronic medication cabinet and administered the drug to Charlene Murphey, a 75-year-old patient.

    Unfortunately, instead of grabbing Versed, a sedative to help calm Murphey before she underwent a scan, Vaught accidentally grabbed vecuronium, a powerful paralyzer that stopped the patient's breathing and left her brain dead before the error was discovered. Murphey ultimately died on Dec. 27, 2017.

    Following the fatal error, the Tennessee Board of Nursing last year revoked Vaught's RN license, effectively ending her nursing career. At the hearing, Vaught admitted her mistake, saying she had become "complacent" in her job and was "distracted" by a trainee while using the computerized medication cabinet.

    "I know the reason this patient is no longer here is because of me," Vaught said. "There won't ever be a day that goes by that I don't think about what I did."

    According to Kelman, Vaught's story would have usually ended there since most medical errors are handled by licensing boards and civil courts. However, in a rare move, Vaught has also been charged criminally with reckless homicide and felony abuse of an impaired adult. If convicted, she could face years in prison for her medical error.

    Will Vaught's trial set a precedent for nurses nationwide?

    As the trial begins, prosecutors plan to argue that Vaught's error "was anything but a common mistake" and only occurred after "she ignored a cascade of warnings," Kelman writes.

    According to documents filed in the case, Vaught had to perform several overrides on the computerized medication cabinet, bypassing at least five warnings that she was withdrawing a paralyzing medication to access vecuronium. In addition, she overlooked a warning on the medication's bottle cap that identified it as a paralytic agent.

    Vaught has acknowledged that she performed an override on the medication cabinet, but said that such overrides are part of normal hospital operating procedures. At her nursing board hearing, Vaught said she had been instructed to use overrides to bypass cabinet delays and technical problems caused by an overhaul of the hospital's EHR system.

    "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."

    Experts following Vaught's case have also said that overrides are a common procedure at many hospitals. For example, Michael Cohen, president emeritus of the Institute for Safe Medication Practices, and Lorie Brown, former president of the American Association of Nurse Attorneys, both said it is common for nurses to use an override to access medication.

    However, Cohen and Brown added that Vaught should not have been able to access vecuronium that easily even with an override. Since Vaught's case, medication cabinet manufacturers have modified the devices' software to make it more difficult to perform an override while searching for drugs, but not all hospitals have implemented this safeguard, Kelman writes.

    Nurses nationwide are following Vaught's case, and many are concerned that a conviction will set a precedent for future criminal charges for medical errors—which could become more common as the pandemic leaves countless nurses exhausted and burnt out, Kelman writes.

    "In response to a story like this one, there are two kinds of nurses," said Janie Harvey Garner, an RN and founder of Show Me Your Stethoscope, a nursing group on Facebook with over 600,000 members. "You have nurses who assume they would never make a mistake like that, and usually it's because they don't realize they could. And the second kind are the ones who know this could happen, any day, no matter how careful they are. This could be me. I could be RaDonda."

    Garner said most nurses know the pressures that could contribute to an error like this, such as long hours, crowded hospitals, imperfect protocols, and the "inevitable creep of complacency in a job with daily life-or-death stakes," Kelman writes.

    In 2019, Maureen Shawn Kennedy, editor-in-chief emerita of the American Journal of Nursing, wrote that Vaught's case was "every nurse's nightmare." Now, during the pandemic, "this is truer than ever," Kelman writes.

    "We know that the more patients a nurse has, the more room there is for errors," Kennedy said. "We know that when nurses work longer shifts, there is more room for errors. So I think nurses get very concerned because they know this could be them." (Kelman, Kaiser Health News, 3/22)

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