By Nurse RaDonda Vaught, of Nashville, Tennessee, made a deadly mistake four years ago when she administered the wrong drug to her patient by accident, which led to their death.
She tried to defend herself during a disciplinary hearing with the Tennessee Board of Nursing last year, but instead of simply losing her license, she is now facing criminal charges for reckless homicide.
At a time when nurses are dealing with staff shortages, burnout, and fatigue, the idea of going to prison for a routine medical error has millions of nurses worried that they could be next.
A Deadly Mistake
Vaught, 38, was working at one of the most prestigious hospitals in the state when the accident occurred. She was getting medicine from an electronic medication cabinet. The patient was supposed to receive Versed, a sedative that’s used to calm patients before they go into the MRI machine. But Vaught grabbed vecuronium, a powerful paralyzer, by mistake. The drug stopped the patient’s breathing, and they became brain dead before Vaught spotted the error.
While making her case in front of the Tennessee Board of Nursing last year, Vaught told the board that she had become “complacent” in her job and was “distracted” by a trainee while operating the computerized medication cabinet.
“I know the reason this patient is no longer here is because of me,” Vaught said as she started to cry. “There won’t ever be a day that goes by that I don’t think about what I did.”
Many nurses would simply have their licenses revoked in this situation, but Vaught’s case is different.
She is about to go on trial for reckless homicide and felony abuse of an impaired adult for the killing of Charlene Murphey, who died at the age of 75 under Vaught’s care.
Experts say it’s rare for a case like this to go to trial. They are often dealt with by civil courts and nurse licensing boards.
Both the Nashville District Attorney and Vaught’s lawyer Peter Strianse refused to comment on the case.
Janie Harvey Garner, a St. Louis registered nurse and founder of Show Me Your Stethoscope, a nursing group with more than 600,000 members on Facebook, said the case is important for several reasons. If Vaught is convicted, it could strike fear into the hearts of millions of nurses at a time when the pandemic and staff shortages could make them more prone to error.
Garner remembers accidentally switching medication, but she caught the mistake before it was administered to the patient.
She says the same thing could easily happen to millions of providers.
“In response to a story like this one, there are two kinds of nurses,” Garner said. “You have the 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.”
According to documents filed in the case, prosecutors will argue that Vaught’s mistake was anything but ordinary. They say there were several warnings that could’ve prevented the error.
They plan on focusing on the electronic medication cabinet. Records show that Vaught initially tried to withdraw Versed from a cabinet by typing “VE” into the search function without realizing she should have typed in its generic name, midazolam. When the cabinet did not produce Versed, Vaught triggered an “override” that unlocked a much larger swath of medications, then searched for “VE” again. This time, the cabinet offered vecuronium.
Prosecutors said that Vaught overlooked five warning signs that could’ve prevented the tragedy.
First, Vaught didn’t notice that Versed is a liquid while vecuronium is a powder that must be mixed into liquid, documents state.
She also had to poke a syringe into the vial, which forced her to “look directly” at the bottle cap that read, “Warning: Paralyzing Agent,” the DA’s documents state.
Vaught argued that overriding the electronic cabinet is part of normal operating procedures. During the hearing with the nursing board, she said the hospital told nurses to use overrides to overcome cabinet delays and constant technical problems caused by an ongoing overhaul of the hospital’s electronic health records system.
She said the patient needed at least 20 cabinet overrides over the last three days of his care.
“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 agree that nurses often have to override the system, but drugs like vecuronium shouldn’t be so easy to access.
“This is a medication that you should never, ever, be able to override to,” said Lorie Brown, past president of the American Association of Nurse Attorneys. “It’s probably the most dangerous medication out there.”
Michael Cohen, president emeritus of the Institute for Safe Medication Practices, said many electronic medicine cabinets ask users to type in at least five letters when searching for a drug during an override to prevent deadly mistakes.
Cohen referenced a “strikingly similar” case where a nurse accidentally reached for verapamil during an override, but that incident didn’t lead to the patient’s death or criminal charges.
Maureen Shawn Kennedy, the editor-in-chief emerita of the American Journal of Nursing, has described Vaught’s case as “every nurse’s nightmare.”
“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.”
