It has been widely reported that nurse Ra Donda Vaught is facing criminal charges for reckless homicide and abuse of damaged adults. The allegations stemmed from a series of inadvertent medication errors committed by Nurse Vaught at Vanderbilt University Medical Center (VUMC). The Nashville district attorney put all the blame on her for the death of Charlene Murphey.
What was not widely publicized is that the CMS Deficiency Report established that Vanderbilt failed to provide standard hospital-wide safe medication practices that could have detected medication errors and prevented the death of Charlene Murphey.
To shed more light on these issues for the benefit of other hospitals, the Institute for Safe Medication Practices (ISMP) has published two newsletter articles to address all of the systemic failures that can contribute to errors associated with the use of neuromuscular blockers. These safe practice recommendations have been provided by the ISMP so that other organizations can implement them to reduce potential errors.
Introduction
ISMP also addressed the circumstances behind this tragic neuromuscular blocker (vecuronium) incident at Vanderbilt University Medical Center.
The ISMP described how safe medication practices that catch medication errors before they harm the patient did not exist at Vanderbilt Hospital at the time of Charlene Murphy's death.
ISMP stated,
"The real problem in this case is that there were no effective systems to prevent or detect the inadvertent selection, removal, and administration of a substituted neuromuscular blocker."
Centers for Medicare & Medicaid Services (CMS) disability report issued to Vanderbilt
In January 2019, national CMS at Vanderbilt research findings highlighted a lack of safe medication practices at Vanderbilt University Medical Center (VUMC). CMS identified extremely serious hospital-wide deficiencies that existed at VUMC at the time of the tragic death of patient Charlene Murphey.
The report showed that Vanderbilt's nurse, Ra Donda Vaught, frankly admitted that she accidentally selected vecuronium from an Automatic Dispensing Cabinet (ADC) override mode. She also admitted to a number of serious mistakes, including administering a fatal dose of vecuronium to the patient and failing to follow up on the patient afterward. She thought that she had administered Versed (midazolam).
- This post is not a defense of the admittedly egregious actions of Nurse Vaught.
CMS investigators also examined the role Vanderbilt Hospital may have played in this tragedy.
Patients at risk without safe medication practices
The CMS report showed that Charlene Murphey's death was the result of human error by Nurse Vaught, along with systemic failures by Vanderbilt Hospital to provide safe medication practices to detect and prevent unintentional medication errors from harming patients. .
CMS cited Vanderbilt in the Disability Report for failing to prevent a preventable death.
Had the hospital employed safe medication practices, Nurse Vaught's human errors could have been quickly corrected before tragedy struck.
Vanderbilt required to provide safe medication practices to qualify for CMS reimbursement
To maintain financial support from CMS, Vanderbilt has submitted an application"Correction Plan". It took 330 pages to specify all the changes.
The CMS Deficiency Report (DEF) appears in the left column of the document below. Vanderbilt's Plan of Remediation (POC) appears in the right column.)
[googlepdf url =”https://hospitalwatchd.wpengine.com/wp-content/uploads/VUMC-PLAN-OF-CORRECTION.pdf”]
The changes confirmed the previous lack of safe medication practices at the time that Ms. Murphy.
1
Vecuronium replacement removed
Nurse Vaught accidentally obtained vecuronium through the ADC. Now, however, Vanderbilt has removed the vecuronium from replacement mode in the ADC. Therefore, this error should never occur again with vecuronium.
2
Vanderbilt implemented barcode scanning in the radiology department
Charlene Murphy received the fatal dose of vecuronium while in the Radiology Department awaiting a PET scan. At that time, the Radiology Department did not have a barcode or second nursing verification. Now, under new safe medication practices, a radiology nurse can barcode a patient's wristband to verify the correct medication. This procedure could have saved Charlene Murphy's life.
3
Vanderbilt implemented the second nursing check in the radiology department
The new system also requires a 2North Dakotanurse to verify the accuracy of the order. That safeguard could have prevented the death of Charlene Murphy.
4
Nurse forced to insert “PARA” in the ADC
Another precaution was added to hospital practices. To get a paralyzing drug from the ADC, a nurse must first type the letters TO. Once again, this safeguard could have prevented the death of Charlene Murphy.
5
Vanderbilt implemented policies to monitor high-risk drugs like Versed or Vecuronium that didn't exist before
Nurse Vaught was accused of failing to monitor Charlene Murphy after administering medication. However,
CMS found that Vanderbilt had no hospital policies or procedures for monitoring patients after administration of high-risk drugs, including Versed and vecuronium. Additionally, there were no policies in place to monitor most patients (except critically ill) during transport to and from departments such as Radiology.
When Charlene was taken to Radiology for a PET scan, the radiology nurse said that Charlene Murphey would need to be monitored after receiving the Versed, but the nurse did not have time to monitor the patient. However, Vanderbilt's lack of monitoring policy was especially clear when Charlene Murphey's primary nurse took the opposite position, telling the radiology tech that there was no need to monitor Charlene after she was administered her prescribed medication, Versed. Thus, the confusion about monitoring has been well established. It seems that Ra Donda, as head nurse, didn't think it was necessary to monitor Versed. (At the time, she was unaware that she had administered vecuronium.)
Vanderbilt has now introduced monitoring policies and procedures for all patients at the hospital. In addition, the hospital created a Radiology Nurse position to monitor radiology patients. Radiological monitoring may have saved Charlene's life while she awaited a PET scan. (There is a reversal drug/agent that counteracts vecuronium.)
Charlene Murphy's death was preventable
If Vanderbilt had followed safe medication practices, Charlene Murphey would not have died.
- Removing vecuronium from ADC replacement mode would have saved the patient's life.
- Writing TO before getting the medicine could have saved the patient's life.
- The barcode in the Radiology Department on the patient's bracelet could have saved the patient's life.
- Two nurses approving the drug in the Radiology Department could have saved the patient's life.
- Follow-up in the Radiology Department could have saved the patient's life.
Vanderbilt administrators failed to provide safe medication practices
The evidence presented by CMS shows that Vanderbilt administrators failed to implement safe medication practices to detect and correct medication errors before harm was done to someone. (It is not yet known what other adverse or fatal outcomes resulted from the lack of safe medication practices.) However, although the hospital terminated Nurse Vaught, there appeared to be no adverse consequences for hospital administrators who did not previously implement these practices. sure.
The district attorney files criminal charges placing all the blame on Nurse Vaught, but hospital administrators are out of the woods
CMS provided substantial evidence of Vanderbilt's inability to provide a "secure environment." Even so, in February 2019, NashvilleThe district attorney accused Nurse Vaughton charges of reckless homicide and abuse of a disabled adult.
The prosecutor tried to argue that Nurse Vaught was fully responsible for the tragedy.
“As you can see in the CMS report, there were safeguards that were overridden,”
the district attorney's office said in an emailed statement to the Tennessee.
However, according to CMS and the Institute for Safe Drug Practices, the necessary safe drug practices or safeguards were not implemented at Vanderbilt.
It appears that the prosecutor has decided to disregard substantial evidence of Vanderbilt's guilt.
The district attorney has a conflict of interest.
Although the district attorney's office has officially denied any conflict of interest for the district attorney, Mr. Funk has several professional and personal relationships with Vanderbilt that raise the appearance of a potential conflict of interest. First of all, Mr. Funk is an adjunct professor of law atVanderbilt Law School.So Mr. Funk performs inVanderbilt Kennedy Center Leadership Councilwith Mrs. Melinda Balser, wife of VUMC CEO Jeff Balser. In addition, Mr. Funk and his wife, Lori Funk, are members ofNext Step Advisory Boardin the Department of Special Education at Vanderbilt Peabody College.
The Lord. Funk appears to have a level of commitment to Vanderbilt that could understandably make it difficult for him to take actions that would damage the reputation or standing of VUMC administrators or doctors.
Since Vanderbilt has not publicly indicated any opposition to the lawsuit against Nurse Vaught, some observers have questioned whether Vanderbilt gave tacit approval to this lawsuit. There was no public support for the accusation from any health entity.
Charlene Murphey's family opposes nursing position
charlene murphey's familyopposed criminal prosecutionof Ra Donda. Charlene's son, Gary, said he knew his mother would have forgiven Ra Donda for her mistakes. He would have been upset if he had known that RaDonda might spend time in prison. She had suffered enough, he said. He also said how he felt about the Vaught family.
“I don't like to see someone's family destroyed. It distorted their lives as much as ours."he says.
Will the prosecution of Nurse Vaught improve patient safety?
Nurse Janie Harvey Garner, founder and CEO of Show Me Your Stethoscope, a Facebook page of more than 650,000 nurses, shared her thoughts on her Facebook site.
“What I do know is that if you sue a nurse for making a tragic but unintentional mistake, we will make nurses less likely to report mistakes. Our organization did a survey and asked how many had made a medication error. And 75% of those surveyed admitted to having made a medication error. And imagine how many others have made one without knowing it.
“…I'm saying that if there's a chance you'll go to prison, you're more likely not to report your mistakes and we know it. The next step would be that if a medication error caused some harm but didn't kill anyone, it could be considered a battery. This case can make patients less safe because nurses are less likely to report their mistake in time to do something about it. This is the reality."
doctor Zubin Damania – “A shameful act”
On his YouTube channel, Dr. Damania commented on the impact of arresting a nurse for inadvertent mistakes.
“It is a shameful act to try to put this woman in jail. She is already paying the price for her mistake. If they're going to jail people, they should also jail all the Vanderbilt managers who oversaw security."
“For those of us who see patients all the time, I ask the question: Who has not made a mistake that harmed a patient? I'm not raising my hand. I made these mistakes. If nurses and doctors are afraid of going to jail, what do you think will happen to bug reporting in the future? We need a system that helps improve when we find bugs to ensure they never happen again.”
The Institute for Safe Medication Practices considers nurse Vaught's accusation "legally unjustified"
“We do not believe that the criminal charges are justified. Although our legal system allows human error to be classified as a crime, even in the absence of intent to cause harm. ISMP does not believe that criminal charges are warranted in this case. In fact, we find it shameful that a nurse who is already suffering and paying the price for her mistake is now facing criminal prosecution and possible prosecution, loss of her nursing license and livelihood, and imprisonment."
“The retrieval of the ADC medication by voiding should not be grounds for criminal prosecution of the nurse, as suggested by the Prosecution, or any other 'void safeguard' unless Ra Donda was well aware that he was making a decision. substantial. and unwarranted risk.
“….The hospital where Ra Donda worked allowed nurses to withdraw certain drugs by substitution, and it is very likely that, prior to this event, midazolam and vecuronium were withdrawn from an ADC by substitution at this hospital. Furthermore, it is unlikely that nurses, including Ra Donda, would perceive any significant or unjustifiable risk in obtaining a substitute drug…”.
“…Whether the nurse made an error in judgment in deciding to get the replacement drug is not the problem;
the real problem in this case is that there were no effective systems to prevent or detect the accidental selection, removal and administration of a substituted neuromuscular blocker”.
(Read thefull newsletter articledo Institute for Safe Medication Practices.)
Will the district attorney sue the Vanderbilt doctors?
Since the prosecutor chose to bring criminal charges against a nurse (who made inadvertent medical errors), some have questioned whether the prosecutor will now prosecute other health professionals, including doctors.
Are there additional cases at Vanderbilt that meet the same standards that the district attorney used to prosecute nurse Ra Donda Vaught? Maybe.
According to a recent court filing, general surgery resident Dr. Gretchen Edwards performed a central line procedure for patient Chesta Shoemaker, who was a registered nurse. During the procedure, Dr. Edwards accidentally punctured a carotid artery while she was allegedly using ultrasound guidance. Unfortunately, the resident did not recognize that the carotid artery had been punctured and did not follow hospital guidelines. According to a specialist doctor who has performed this procedure several times, it is very difficult not to notice blood spurting out of an artery at high pressure. Three Vanderbilt doctors (Gretchen Edwards, Richard Betzold, Amanda Craig), testified under oath in statements that the assistant, Addison May, was not present.
In addition to acknowledging the initial surgical error, the Vanderbilt resident was also unable to identify the error during the critical hours following the procedure. Tragically, this surgical error cut off the flow of blood and oxygen to the brain, causing Chesta Shoemaker to suffer a stroke. According to court records, the punctured artery and the lack of proper medical care that followed led to the patient's death. But the mistakes turned into violations of state law when Vanderbilt orchestrated a cover-up of the tragedy.
In violation of a state statute, the medical examiner was not called. In violation of another state statute, Vanderbilt administrators failed to file a Health Department Incident Report within 7 business days. Finally, Vanderbilt's neurologist, Eli Zimmerman, falsely certified on the death certificate that the death was natural. The neurologist omitted the underlying cause required on the death certificate. The underlying cause of death for Chesta Shoemaker was a punctured carotid artery. (Dr. Zimmerman also falsely certified that Charlene Murphey's death was natural.)
Should this case be taken to a grand jury for possible criminal prosecution of resident Gretchen Edwards?
Whether you're a nurse or a doctor, we don't think the DA should criminalize unintentional errors made by doctors. It'spoint of viewit was also reported on Health News for NPR.
Medical boards supervise licensed physicians
The Nashville DA appears to have thrown out the long-established precedent of relying on medical boards to oversee licensed health practitioners. In Tennessee, the Department of Health's Office of Investigations handles all investigations of licensees. The Board of Nursing does not conduct investigations.
In memory of Charlene Murphy
The Murphy family responded to this tragedy with courage and dignity. They objected to Nurse Vaught's accusation, as they know that this is how Charlene would want it.
After CMS uncovered Vanderbilt's nearly year-long cover-up of this case, Vanderbilt never apologized to the family for lying about Charlene's death and forging her death certificate.
Our hearts go out to the Murphy family for what they endured. There is some comfort in knowing that Vanderbilt administrators were required to introduce safe medication practices to prevent further harm to patients.
It is estimated that the number of patients who die each year from medical errors ranges from 250,000 to 440,000. For the families of those who have passed away, change always comes too late. Hospitals can do much more to reduce medical errors.
(This post represents a team effort of volunteers at Watchdog Hospital.)
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FAQs
What did Vanderbilt Hospital do wrong? ›
CMS stated that Vanderbilt hospital policy was inadequate because it failed to detail “any procedure or guidance regarding the manner and frequency of monitoring during and after medications were administered.”
What did the Vanderbilt nurse do wrong? ›RaDonda Vaught, a former nurse at Vanderbilt University Medical Center, had been found guilty in March of two charges, criminally negligent homicide and abuse of an impaired adult, after a medication error contributed to the death of 75-year-old Charlene Murphey in December 2017.
What medication did the Vanderbilt nurse give the wrong patient? ›Murphey was prescribed Versed, a sedative, but Vaught inadvertently gave her a fatal dose of vecuronium, a powerful paralyzer. Charlene Murphey's son, Michael Murphey, testified at Friday's sentencing hearing that his family remains devastated by the sudden death of their matriarch.
What was the nurse from Vanderbilt found guilty of? ›What are RaDonda Vaught's convictions? A jury convicted Vaught in March on two charges, criminally negligent homicide and abuse of an impaired adult.
What did RaDonda Vaught do to patients? ›However, Vaught overrode the medical cabinet and withdrew the wrong medication. She mistakenly administered the powerful paralytic vecuronium instead, which led to total muscle paralysis and stopped Murphey's ability to breathe and caused her death.
Why are nurses leaving Vanderbilt Hospital? ›NASHVILLE, Tenn. (WSMV) - Nurses across the country say they are quitting their jobs after RaDonda Vaught was found guilty. A jury found Vaught, a former Vanderbilt University Medical Center nurse, guilty of criminally negligent homicide.
How many years of experience did RaDonda Vaught have as a nurse? ›An emergency room nurse for 14 years, she said she broke down crying when Vaught was found guilty. “Never in my 14 years have I felt so helpless,” she said.
What is the Vanderbilt controversy? ›The Vanderbilt rape case is a criminal case of sexual assault that occurred on June 23, 2013, in Nashville, Tennessee, in which four Vanderbilt University football players carried an unconscious 21-year-old female student into a dorm room, gang-raped and sodomized her, photographed and videotaped her, and one urinated ...
What nurse went to jail for med error? ›RaDonda Vaught, the Tennessee nurse convicted after a medical error led to a patient's death, was sentencedopens in a new tab or window to 3 years of supervised probation, evading a possible prison sentence of up to 8 years.
Is RaDonda Vaught still nurse? ›Following the fatal error, the Tennessee Board of Nursing last year revoked Vaught's RN license, effectively ending her nursing career. Vaught was also charged and ultimately found guilty of gross neglect of an impaired adult and negligent homicide. She faced up to eight years in prison.
What did RaDonda do correct after realizing her mistake? ›
Vaught reported her error as soon as she realized what she had done wrong — injected the paralyzing drug vecuronium instead of the sedative Versed into 75-year-old Charlene Murphey on December 26, 2017.
How did Vaught give the wrong medication? ›The tipster reported Nurse Vaught was orienting a new registered nurse when the patient's nurse asked Nurse Vaught to give Versed to the patient. The report goes on to state that Nurse Vaught removed the incorrect drug, did not read the label, and accidently administered vecuronium instead of Versed.
Was RaDonda Vaught an ICU nurse? ›When RaDonda Vaught, 38, a former ICU nurse, saw her patient's condition she knew she had made a mistake.
What medication error did nurse RaDonda Vaught have? ›There is no doubt that Vaught made a grave error when she gave her patient an injection of vecuronium, a muscle relaxant that left the 75-year-old woman unable to breathe, instead of Versed, a sedative.
Did the Vanderbilt nurse lose her license? ›' Board votes to revoke former Vandy nurse's license. NASHVILLE, Tenn. (WTVF — The Tennessee Board of Nursing voted to revoke a Former Vanderbilt University nurse after she admitted to using the wrong medication which ultimately killed the patient.
What happens to a nurse who makes a medication error? ›For a nurse who makes a medication error, consequences may include disciplinary action by the state board of nursing, job dismissal, mental anguish, and possible civil or criminal charges.
Is RaDonda Vaught working now? ›Vaught is now working on the family farm while on supervised probation. Her record can be expunged after three years.
What precipitated the error of nurse RaDonda and why do you think so? ›The fatal medical error resulted from Vaught's interactions with an electronic medication cabinet, where nurses must enter the first part of the medication's generic name to withdraw a drug.
How much do Vanderbilt nurses make? ›$44. The estimated total pay for a Registered Nurse at Vanderbilt University Medical Center is $44 per hour.
Is nurse Radonda going to jail? ›A former Tennessee nurse convicted in the 2017 death of a patient due to a fatal drug error will serve no jail time.
What is the least stressful nursing job in the hospital? ›
- Nurse Educators. ...
- Institutional Nurses. ...
- Research Nurses. ...
- Public Health Nurses. ...
- Occupational Health Nurses. ...
- Case Management Nurses. ...
- Home Health Nurses. ...
- Clinic Nurses.
Former Vanderbilt University Medical Center nurse RaDonda Vaught will not serve jail time after making a medication error that resulted in the death of a patient.
What meds did RaDonda mix up? ›RaDonda Vaught, 37, was also found guilty Friday of gross neglect of an impaired adult in a case that has fixed the attention of patient safety advocates and nurses' organizations around the country. Vaught injected the paralyzing drug vecuronium into 75-year-old Charlene Murphey instead of the sedative Versed on Dec.
What 3 things did Vanderbilt do? ›Cornelius Vanderbilt began a passenger ferry business in New York harbor with one boat, then started his own steamship company, eventually controlling Hudson River traffic. He also provided the first rail service between New York and Chicago.
Why were the Vanderbilts forced out of the breakers? ›"A year-long study by a preservation architect and an engineer concluded that the ventilation, electrical, and plumbing systems, while completely safe for museum use, were dangerously outdated for residential use, putting the structure and collections at risk," this week's announcement said.
Did a Vanderbilt go down with the Titanic? ›Alfred Gwynne Vanderbilt
The 34-year-old multimillionaire sportsman, an heir to the Vanderbilt shipping and railroad empire, was returning from a trip to Europe and canceled his passage on the Titanic so late that some early newspaper accounts listed him as being on board.
[1] Among the problems that commonly occur during providing health care are adverse drug events and improper transfusions, misdiagnosis, under and over treatment, surgical injuries and wrong-site surgery, suicides, restraint-related injuries or death, falls, burns, pressure ulcers, and mistaken patient identities.
Why did RaDonda go to trial? ›The RaDonda Vaught homicide case was an American legal trial in which former Vanderbilt University Medical Center nurse RaDonda Vaught was convicted of criminally negligent homicide and impaired adult abuse after she mistakenly administered the wrong medication that killed a patient in 2017.
Did RaDonda Vaught have a preceptor? ›Kessinger was Vaught's preceptor, she helped train Vaught in Vanderbilt's ICU. Kessinger testified that Vaught was motivated, very attentive with patients and spent quality time with them outside of medical care.
What degree did RaDonda Vaught have? ›
Vaught, 38, graduated from Western Kentucky University and was licensed as a registered nurse in the state in February 2015. Vaught was hired at Vanderbilt in October 2015 and was fired less than a month after Murphey's death. She had no record of medical discipline prior to the patient's death.
Did nurses walk out at Vanderbilt Hospital? ›RaDonda Vaught: Nurse resigns in response to Ex-Vanderbilt nurse's guilty verdict.
What are the 5 rights of medication? ›One of the recommendations to reduce medication errors and harm is to use the “five rights”: the right patient, the right drug, the right dose, the right route, and the right time.
Did RaDonda Vaught reconstitute the medication? ›Vaught reconstituted the medication and administered a dose to Murphey. Vaught did not remain with Murphey to monitor the effects of the medication as she was taken back for her scan. There was no identified protocol for monitoring a patient in the radiology department at that time.
What Vanderbilt nurse was charged with manslaughter? ›RaDonda Vaught, left, with her attorney, Peter Strianse, right, was charged with reckless homicide and felony abuse of an impaired adult after a medication error killed a patient. She was convicted of the lesser charge of negligent homicide. The name RaDonda Vaught is now well-known by nurses nationwide.
What happened to the nurse that gave the wrong medication? ›Former Tennessee nurse RaDonda Vaught found guilty in woman's death after accidentally injecting her with wrong drug. A former Tennessee nurse has been found guilty of criminally negligent homicide in the death of a patient who was accidentally given the wrong medication, a jury found.
Why was the nurse criminally charged? ›Nurse RaDonda Vaught convicted of 2 felonies for fatal medical error : Shots - Health News RaDonda Vaught's conviction could lead to years in prison. It's a rare case of a medical mistake being deemed a crime, and many worry it will have a chilling effect on the entire nursing profession.
What is RaDonda doing now? ›But for RaDonda Vaught, a nurse in Tennessee, a medication error that she immediately recognized and tried to fix, but still turned out to be fatal, has landed her on trial for murder. She is now currently on trial for reckless homicide and adult abuse.
Is RaDonda doing jail time? ›RaDonda Vaught sentenced to 3 years probation for fatal medication error. A former Tennessee nurse convicted in the 2017 death of a patient due to a fatal drug error will serve no jail time.
What type of nurse was RaDonda Vaught? ›Vaught's lethal error, explained
On the day after Christmas in 2017, RaDonda Vaught was working a shift as a “help all” nurse in the neurologic intensive care unit at Vanderbilt University Medical Center.
What is the most common medication error in nursing? ›
Errors may be potential -- detected and corrected prior to the administration of the medication to the patient. The three most common dispensing errors are: dispensing an incorrect medication, dosage strength or dosage form; miscalculating a dose; and failing to identify drug interactions or contraindications.
Who is responsible if a patient gets the wrong medicine? ›Prescribing errors and order communication is generally the first patient's interaction with a possible medication error injury. During this process, the doctor is generally the individual who may be responsible for errors and mistakes.
What nurse was found guilty of negligence? ›International Council of Nurses reacts to sentencing US nurse found guilty of negligent homicide. The International Council of Nurses (ICN) says it is grateful that the sentence given to United States nurse RaDonda Vaught following a medical error, was less harsh than had been feared.
Do nurses go to jail for mistakes? ›Nurses' mistakes often appear in medical malpractice lawsuits but criminal prosecutions are exceptionally rare. The victim's son told The Tennessean his mom would have forgiven Vaught and would be very upset that she could spend some of her life in prison.
Why nurses are quitting? ›Nearly the same amount said their patients are suffering because they have too much on their plate, the survey found. Nurses also said their jobs offer little flexibility over their schedules, leaving them with little time to spend with friends and family and not enough opportunities to advance in their careers.
What medication did the nurse give wrong in 2017? ›The nurse, RaDonda Vaught, apologized to the relatives of the 75-year-old victim, Charlene Murphey, who was injected with a fatal dose of vecuronium, a paralyzing drug, instead of Versed, a sedative, while at Vanderbilt University Medical Center for a brain injury on Dec. 26, 2017, according to court papers.