Nurse Radonda Vaught was arrested on February 4 and charged with reckless homicide and patient abuse following a medication error which led to the death of an elderly patient – a case reminiscent of the Kim Hiatt tragedy. The health care community is responding with shock and outrage at the implications of a criminal charge of this nature for future patient safety and the morale of health care professionals.
At Vanderbilt University Medical Center, a full body scan was ordered for Charlene Murphy in December 2017, after she had suffered a subdural hematoma. Versed was prescribed as 75-year-old Murphy had expressed anxiety and reported that she suffered from claustrophobia. Vaught, who was a relief nurse in the particular ICU on the day, accompanied the patient to the radiology department and was unable to obtain the Versed from Pyxis. She overrode the system and withdrew the first medication which came up after she had typed in “Ve” – this was vecuronium, a powerful neuromuscular blocking agent that leads to paralysis. During the half-hour that the patient was in the scanner, she became unconscious and suffered a cardiac arrest. She never recovered and was declared dead the following day.
The hospital had failed to report the incident to the Tennessee Department of Health and the matter only came to light nearly a year later when it was discovered during a site survey by the Centers of Medicare and Medicaid Services (CMS). At this point, the hospital issued a statement that immediate corrective action had been taken at the time of the incident – which apparently included Vaught’s dismissal.
An investigation by the CMS followed, and the prosecutors apparently built their case against Vaught on their report. “As you could tell from the CMS report, there were safeguards in place that were overridden,” wrote Steve Hayslip, in an email statement from for the Davidson County District Attorney’s Office. “By the definition of “reckless,” the defendant’s actions justify the charge.” Vaught was released on a $50,000 bond and is due in court on February 20.
A casualty of second victim syndrome
The patient’s family was not interested in making a civil case against Vaught. Her son told The Tennessean that he believed that his mother would forgive her and feel sorrow that a mistake was now destroying two lives.
While acknowledging the fact that Vaught had clearly made a tragic and avoidable medication error, comments on the web by health care professionals are mostly expressing shock and outrage both at the criminalization of an error and that there were no apparent consequences for the hospital administration.
“I read the CMS report in its entirety, and it’s a laundry list of systems errors,” commented Bre-anne Brown. “Yes, the nurse has a professional responsibility […] But the hospital was just drowning in inadequate systems and utterly insufficient institutional response. She is absolutely being hung out to dry as a scapegoat.”
PulmCCM posted a review on the case in which they explained that prosecution for medical errors or professional negligence were extremely rare. Charges of homicide against health care professionals were normally reserved for intentional harm or practicing without a license. “A primary argument against prosecution is that because medication errors occur so frequently, usually without harm to the patient, and often largely due to system factors, it is unjust to selectively prosecute (or discipline severely) those nurses whose patients happen to be harmed. This principle is referred to as just culture. Also, fear of prosecution undermines the culture of safety, including open disclosure of errors without fear of punishment, that health care leaders seek to promote.” That the latter is true is supported by a comment from Jon Bigaouette “Because that’s how you get a culture where nurses cover up every mistake they make, and the system never gets fixed.”
The issues around Vaught’s arrest are highlighted in the discussion by Z-DoggMD. He emphasizes that a frontline health care provider was being thrown under the bus for a mistake that was partly contributed to by many other failures in the system. The nurse did make mistakes, but “does that mean you go to jail for that? Who here hasn’t made a mistake that’s harmed a patient?” he asks. “What we need is radical transparency…a system that helps to improve itself when we find errors…we need accountability from our leadership…” He also called for support for Vaught, whose license was not rescinded by the Tennessee Board of Nursing after they looked at her case, and said that he believed that as a second victim she was suffering enough.