A Vanderbilt University Medical Center nurse made a devastating medication error that resulted in the death of a 74-year-old woman, Ms. Charlene Murphey. The nurse, RaDonda Vaught, was convicted of two felonies, for which she will soon be sentenced.
When using the electronic medication cabinet to obtain a sedative for a patient, Ms. Vaught withdrew the powdered drug vecuronium, instead of the drug she was looking for, liquid Versed. Vecuronium is a paralytic, while Versed is a sedative. Ms. Vaught failed to recognize or bypassed five alerts and proceeded to mix the vecuronium powder into solution. While overriding the system sounds outrageous, Ms. Vaught testified in her criminal trial that Vanderbilt had instructed nurses to use overrides due to chronic technical problems with the electronic cabinet. The use of overrides with drug cabinets is not unusual—though the result can be, and was, fatal.
The error and criminal conviction of Ms. Vaught shocked the medical and patient community. While the public may feel triumph that a bad actor is facing prison time, and healthcare consumers may look for prosecution of others who commit medical errors, the situation is anything but clear.
Medical mistakes are common across practice areas and practitioners. While many of these mistakes do no harm, or are “near misses,” medical errors that cause disabling and deadly injury are frequent. We often discuss types of medical error, how it occurs, and the necessity of strong legal representation to obtain compensation for injuries suffered and mistakes made. Despite the dismal frequency of medical error in the US, the criminal pursuit of a healthcare practitioner for an unintentional medical error is rare.
A groundbreaking report issued by the Institute of Medicine (IOM) in 1999 entitled “To Err is Human: Building a Safer Health System” opened the door for discussion of medical errors that occur in the US. At the time, it was estimated between 44,000 and 98,000 people died annually due to medical mistake. While there is no agreement on the current death toll of patients who die each year due to medical error, there is full agreement that the number of errors and resulting injuries and deaths are too high.
A critical component of addressing the root cause of medical error, wherever it occurs, is understanding when and how it occurs. Solid research supports the need for a non-judgmental healthcare environment that promotes self-reporting, investigation, and discussion of medical mistakes. Only through understanding what happened—whether it caused harm or not—can strategic, administrative, and hands-on processes be created or revised to avoid future harm.
The Vaught conviction sent a chilling ripple throughout the medical community. Given the fatigue and trauma of the COVID-19 pandemic, many healthcare practitioners have already exited the practice of medicine. Resulting staffing shortages exacerbate already stressful and distracting hospital environments. Physicians, advanced practice providers, and nursing staff are rethinking career choices given the current state of healthcare in their hospitals and in the courtroom. Looking at the conditions in which they work which are completely beyond their control, some nurses have already quit following the Vaught conviction.
About the Vaught case, Linda Aiken, a nursing and sociology professor at the University of Pennsylvania, notes, “One thing that everybody agrees on is it’s going to have a dampening effect on the reporting of errors or near misses, which then has a detrimental effect on safety.”
A 2019 investigation of the incident by the Centers for Medicare and Medicaid Services (CMS) led to a deficiency report against Vanderbilt Medical Center. An agent with the Tennessee Bureau of Investigation testified that the Department of Health found that Vanderbilt played a significant role in the medication error and “carried a heavy burden of responsibility in this matter.” The agent then noted there was no disciplinary action against Vanderbilt because “a malpractice error has to be gross negligence before they can discipline for it.”
In almost all cases of serious medical error, there is system error, institutional deficiencies that contribute to the frontline errors attributed to staff. Ms. Vaught, who lost her nursing license, accepts responsibility for her actions and believes her errors occurred against a larger backdrop of “technical problems and flawed procedures” at Vanderbilt that contributed to the devastating result. Vanderbilt was not criminally prosecuted.
The office of the Nashville district attorney explained the conviction as “not an indictment against the nursing profession or the medical community. The jury found that Vaught’s actions were so far below the protocols and standard level of care, that the returned a guilty verdict in less than four hours.”
The Vaught conviction further pushes a fraught medical system past its breaking point. The actions of Ms. Vaught resulted in the tragic death of Ms. Murphey. A medical malpractice lawsuit was not necessary in this case as Vanderbilt Hospital quietly fired Vaught and negotiated a confidential settlement with the family of Ms. Murphey. Money will not restore the life of Ms. Murphey, but it provides the monetary measure by which our society has responded to medical mistake—at least until now.
Medical malpractice litigation is a civil remedy to the egregious errors committed within the healthcare system that injure patients. With the Vaught foray into criminal prosecution of medical error, Americans may need to accept long-term shortages of healthcare providers and nurses as students steer clear of medical and nursing careers. While strides have been made since the IOM report in 1999, the hospital industry has not committed to the kind of change that would have made the death of Ms. Murphey an exception, rather than a too-common outcome.
Baltimore, Maryland medical malpractice law firm helps you after you are injured through medical mistake
Schochor, Staton, Goldberg, and Cardea, P.A. has an established track record of obtaining compensation on behalf of clients and their families injured by medical malpractice and negligence. If you are injured by a healthcare provider, call us at 410-234-1000 to set up a free consultation to discuss your case.