RaDonda Vaught, a former nurse at Vanderbilt University Medical Center (VUMC), was found guilty of gross neglect of an impaired adult and negligent homicide on Friday, following a medical error in 2017 that led to the death of a patient.

Radio Advisory episode: Supporting RNs by changing the structure of nursing

Background

In 2017, Vaught 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 in 2021 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.

Vaught was criminally charged with reckless homicide and gross neglect of an impaired adult.

Vaught found guilty

During the trial, the prosecution argued that Vaught irresponsibly ignored several warnings when obtaining medication. "This wasn't an accident or mistake as it's been claimed," said Assistant District Attorney Chad Jackson. "There were multiple chances for RaDonda Vaught to just pay attention."

Vaught's attorney, Peter Strianse, argued that Vaught made an honest mistake, saying she couldn't have behaved "recklessly" if she believed she was giving her patient the right medication, adding that there was "considerable debate" over whether the vecuronium killed Murphey. Strianse added that Vaught was being used as a "scapegoat" for problems related to VUMC's medication cabinets.

Leanna Craft, a nurse educator at the neuro-ICU unit at VUMC, said it was common for nurses to override the system to get drugs, as there were often delays in retrieving medications from the automatic drug dispensing cabinets.

However, Terry Bosen, VUMC's pharmacy medication safety officer, testified that while VUMC had some technical errors with its medication cabinets in 2017, those issues were fixed weeks before Vaught used the wrong medication on Murphey.

Donna Jones, a nurse legal consultant, testified that Vaught violated the standard of care nurses are expected to maintain. Vaught not only grabbed the wrong medication but also failed to read the name of the drug, notice a red warning label on the medication, and stay with the patient to see if they had an adverse reaction, Jones said.

The jury ultimately found Vaught guilty of gross neglect of an impaired adult and negligent homicide but acquitted her of reckless homicide.

Vaught is scheduled to be sentenced on May 13 and faces three to six years in prison for neglect and one to two years for negligent homicide, according to sentencing guidelines from the Nashville district attorney's office.

Reaction

Following the verdict, the American Nurses Association (ANA) issued a statement saying the case sets a "dangerous precedent" of "criminalizing the honest reporting of mistakes" and could have a "chilling effect" on medical error reporting in the future.

According to ANA, some medical errors are "inevitable," and there are more "effective and just mechanisms" to addressing those errors than prosecution.

"The nursing profession is already extremely short-staffed, strained, and facing immense pressure—an unfortunate multi-year trend that was further exacerbated by the effects of the pandemic," ANA said. "This ruling will have a long-lasting negative impact on the profession."

ANA added the case "must serve as [a] reminder that vigilance and open collaboration among regulators, administrators and healthcare teams is critical at the patient and system level to continue to provide high-quality care."

Bruce Lambert, a patient safety expert and director of the Center for Communication and Health at Northwestern University, who was interviewed before the verdict, said Vaught's case was extremely concerning.

"This will not only cause nurses and doctors to not report medication errors, it will cause nurses to leave the profession," Lambert said.

"What's happened here is that health care has been completely changed," said Janie Harvey Garner, founder of the nurse advocacy organization Show Me Your Stethoscope. "Now when we tell the truth, we're incriminating ourselves." (Kelman, Kaiser Health News, 3/25; Gamble, Becker's Hospital Review, 3/25; Timms, Nashville Tennessean/USA Today, 3/25; Loller, Associated Press, 3/25)