Former Vanderbilt nurse RaDonda Vaught was convicted of criminally negligent homicide and abuse of an impaired adult … for a medication error.
It was a tragic error that many nurses have told me could have happened to many of them: crappy tech, poor systems, understaffing, and human error leading to the death of a vulnerable patient. And now we have the conviction of a nurse on criminal charges for such a mistake. Here are my thoughts on why this is a TERRIBLE precedent for anyone working in healthcare.
Additionally, read statements from the American Nurses Association (ANA) and American Association of Critical Care Nurses (ACCN) regarding the criminal conviction.
And check out my prior episodes discussing Vaught’s case.
– [Zubin] This news that nurse RaDonda Vaught, who was a former Vanderbilt University Medical Center nurse up in the ICU, was just convicted of criminally negligent homicide and abuse of an impaired adult for a medication error.
All right, anybody who’s watching in healthcare right now is getting very upset, I’m gonna bet, because this is incredibly unusual to criminally convict someone for a medical error. And I’m gonna tell you why I think this is terrible for patient safety, it’s terrible for morale, and it’s terrible for the future of nursing and medicine. And it is more evidence of despite being called healthcare heroes and being put in harm’s way constantly and being subjected to moral injury daily with crappy systems and garbage support and terrible technology and horrible payment models and terrible staffing, all this stuff, the people who do that, who set that up, the system makers, the administrators, the hospital, nothing happens to them, and this nurse gets convicted of a criminal charge.
All right, let me recall this story for people who don’t know it, and I linked to some videos that I did back into 2019 when this first came out that she was being criminally charged. Okay, so here’s the story. RaDonda Vaught, I think she’s an ICU nurse, 2017, she is on service. She’s charged as the help-all nurse. So I guess they float or something. I’m not sure of the exact details. But she’s up in the neuro ICU and there’s a patient, Charlene Murphey. She’s 75. She was admitted with a head bleed. Getting better, they wanted to send her down to the scanner, the CT scanner, to rescan her brain bleed to see if she was okay for the next step of care or discharge or whatever it was. So pretty standard stuff.
Nurse Vaught is assigned to her care to take her down to the scanner so that she can get her scan. With her that day is a trainee, so a new person who’s being oriented. So RaDonda Vaught has to train this nurse and she’s with her and so on and she’s going to a part of the hospital she doesn’t always go to, radiology. Now, they go down there. This patient, Charlene Murphey, had claustrophobia. So the doctor had ordered Versed, midazolam, a sedative to give her in the scanner if she felt claustrophobic. And the nurse, again, goes down to accompany the patient and also to provide medications and support like that. So they go down there. The patient needs the medication.
So at this point, Nurse RaDonda goes to the medication dispensing unit, whether it was a Pyxis or one of the other automated dispensing units. Those units are supposed to talk to pharmacy and your electronic health record. In this case, they had gone live with Epic at Vanderbilt, yay, and they were having problems with the communication between the order sets in Epic and these medication dispensing systems through which nurses get the medicine out. So RaDonda puts in the medication name and nothing comes up. So clearly she types in VE for Versed. She didn’t type in midazolam, which is usually better to do because it’s the generic name. Types in VE and nothing comes up in the patient’s orders, et cetera. So she cannot dispense the drug. Well, at that point, she does something, and shows the trainee how to do it, that a ton of nurses at that facility and around the country have to do all the time, including that day, an override. Ah, the medicine’s not showing up. Well, it’s probably a technical glitch, technology, some disconnect between EHR and that, happens all the time. So she overrides, which then allows her access to a broader range of medications. She then types in VE again for Versed and automatically up populates a medication. She dispenses the medication assuming it’s Versed but it turns out it was vecuronium.
Vecuronium, for people who don’t know, is a muscle paralytic agent. It’s used to paralyze patients along with other medications like sedatives so that they don’t, they’re not awake and aware while they’re paralyzed so that you can do things like mechanically ventilate them and other things that require paralysis, like during surgery, et cetera. So vecuronium is also used in lethal injections as part of a three-drug cocktail. It is one of the most deadly medications we have. And it’s there in the same Pyxis or the same medication dispensing unit, again, I don’t know what the brand was that they were using, as the other drugs down in radiology.
Now, remember, in radiology, they also didn’t have access to a bracelet scanner that would’ve scanned the patient’s bracelet and then the medication to confirm that everything was correct. So they were missing that link of it. You know, RaDonda’s the help-all nurse that day, she’s got a trainee with her, and they’re already having technical difficulties that were happening throughout the hospital.
These holes in the Swiss cheese are starting to align where disaster’s gonna strike, all right? And by the way, if you think this is unusual in hospitals, you are deluding yourself. Hospitals are the single most dangerous place on earth, short of Mariupol. They are full of potential pitfalls, errors, cetera, and they’ve gotten safer, but there’s still so much work to do and here’s a great example of why.
She pulls out the drug. There are popups in the the medication dispenser that say, paralytic agent warning. She silences them. Okay, why would she do that? What would be an explanation for why that would happen? And again, I’m gonna say this right upfront, I’m not excusing anything she’s done. I’m explaining how these mistakes can happen and what we might do to make them better. Why would she close a popup that says, warning paralytic agent, right? Which should have told her, “Oh, that’s not Versed. That’s not a paralytic agent.” Because we get popups for every single thing we do, practically. If you try to give aspirin and a Band-Aid, it’ll give you a popup. You know, aspirin can cause bleeding and is contraindicated with Band-Aids. So it’s stuff like that. It’s called alarm fatigue or alert fatigue. You start to tune it out.
Okay, another Swiss cheese hole, alarm fatigue, closes the box, pulls out the medicine. The medicine says on it, vecuronium. It says paralytic agent. Now, normally you’re supposed to read out the medication, confirm it. A lot of facilities have two nurses to check when a serious drug like that is given. Like, Pyxis would say, “You need two nurses to confirm,” et cetera. You gotta scan the thing. There’s different protocols in place. They did not have that here, okay? So now you have a deadly drug. She misses the name on the thing. I’m imagining, and again, it’s hard to know, that she, you know, has a trainee, she’s distracted, she’s in a different place, maybe she’s complacent and she’s just done this so many times, she just goes through the motions, which is not good, but that’s what happens to humans sometimes, right? And she goes to give the drug and it’s a powder instead of a liquid.
Well, it turns our Versed is a liquid. But this powder, vecuronium, you have to actually reconstitute. So you have to put in saline or whatever, mix it, and then draw it out. So she went through all that on autopilot without thinking, “Oh, this is not the drug that I’m normally giving as Versed.” Probably talking to the trainee. Who knows what’s going on, right? At this point, and again, we’ve heard from her. This is her description of what’s happening. At this point, she has one last chance. She looks at the thing. It says paralytic agent on the rim. Pulls out the drug, administers it to the patient, rolls the patient into the scanner. Doesn’t stay with the patient to look for a adverse reaction, which is standard procedure, right? So she did not do that. And I don’t know what Vanderbilt’s procedure is, but that’s something that we standardly do when you give a medication, including Versed because it’s a sedative and you wanna make sure a patient’s still breathing, they’re not having a reaction, everything’s okay. And then patient waits for an hour for the nucleotide they gave her as part of the scan. I think maybe it was a PET scan, actually, they were doing.
And at this point, they come in getting ready to actually do the scan and they find that she’s had a cardiac arrest, she’s pulseless. They do CPR. Everything’s going on. They recover her. But then a subsequent scan of her brain shows just anoxic brain injury. She’s been starved of oxygen and they withdraw support like that evening. So this patient, Charlene Murphey, 75, who would’ve been okay leaving the hospital, died paralyzed, not sedated, wide awake, in a radiology suite alone. Right. That is horrible. It is a tragedy. It’s the one of the worst things you can imagine, okay? And it’s because this mistake was made, this series of mistakes.
Now, you could see why somebody, you know, a patient advocate or somebody who doesn’t know the situation closely would say, “This is horrible. This nurse should be criminally charged with murder.” Yeah, until you actually know what’s going on here and go, “Wait, hold on. This was terrible.” So what happened? What went wrong? How much was system problems? How much could have happened to anybody? How much of it was really a negligent complacence? And what do you do about it, right? So this is what, this is what RaDonda Vaught did. If she knew she was gonna go potentially to jail and be criminally convicted and lose her nursing license, which she did, would she have done what she just did? Which is this, “Oh, my gosh, I made a terrible mistake. I think I pulled vecuronium instead of Versed and here’s how it happened and I gave it, oh, my God,” and immediately told the entire truth to everybody there who was listening.
And this is what Vanderbilt did. They didn’t document this as medical error as the primary cause of death. They said natural causes. They said maybe medication error. I forget exactly the details. They did not report it to the state. They did not report it to CMS. They didn’t do the typical reporting you’re supposed to do when you have a major medical error that is a combination of systems and human error. They did none of that. I don’t even think the family understood exactly what had happened. But this is what happened to RaDonda for telling the truth. And by the way, she was devastated, devastated by this because she’s a good person and a nurse and a caregiver and went into this to help people. And she goes in, I think, talks to people, she’s fired. No process, just fired.
That is not the process that I describe in the video I linked on Just Culture, on how you deal with these situations. Okay, so she’s fired. Nothing happens for a year, all right? Roughly. And an anonymous tip comes into the Tennessee investigative board and I think CMS, I forget, saying, “Hey, this thing was a medication error that they never reported.” And CMS starts to investigate, Center for Medicaid & Medicare Services, right? And they start to investigate and this is what they find. Holy crap, Vanderbilt didn’t report this. There’s all the computer dischronies that could lead to terrible tragedies. There are systems problems. There was like a big report. Vanderbilt had to respond. It was a huge deal. And now it becomes more public. And by the way, so Vanderbilt settles with the family and puts a gag order on them saying, “You cannot publicly talk about this case.” This was later. So then what happens? Well, you know, the nursing board had actually been aware of what had happened, had said, “Oh, this is not something we need to pursue further. It’s a medication error.” You know, they’ve gone through the process, whatever. They then reopen the case, try RaDonda Vaught and the nursing board, and take her license away to practice nursing in that state, which good luck getting a nursing job somewhere else, right? So that’s the end of her career.
You know, this poor patient has died. And the series of errors, the system errors of having a Pyxis that contains vecuronium in radiology, not having them communicate with the EHR properly, allowing an override without a two-nurse confirmation of a dangerous medication, not having the bracelet scanner down in radiology, understaffing, all the other systemic errors and systemic stressors that happen to nurses. And then a nurse who said, admittedly, “I’d become complacent,” because nursing is freaking hard and you become, you have to go with certain routines. And when you’re documenting and you’re looking at a chart all day and you’re suffering constant moral injury from having to do all this garbage and not actually look at the patient in the eye and spend time and hold their hand when they’re having the worst day or worst week or worst month of their life, all that starts to wear on people, right? Now, that’s no excuse for what happened. But this is what ended up happening. Then the Prosecutor’s Office got wind of this and said, “This is criminal. This is actually reckless homicide,” and charged her criminally.
All right. This is rare in healthcare to have criminal charges for a fatal medication error, and that’s because of a couple of things. One, there should be processes in the hospital, a Just Culture process, which I talk about in this other video, where you go through these issues when there’s a mistakes made. How much are systemic? How much are individual? How much can be remedied by education? Now, why is that important? Because if you criminalize a medical error, all right, who is gonna report the truth? RaDonda told the truth and she could go to jail for it. She’s been convicted of a crime for telling the truth and making a mistake and being honest about it and caring about the family and constantly saying, “I feel terrible and I hope the family gets closure from this.” This is how nurses are rewarded. They’re thrown under the bus.
What happened to Vanderbilt? Oh, they had to, you know, type up a report and you know… Where does the shit flow? It always goes downhill. So I have heard from hundreds of nurses around the country who have said, and doctors who have said, “Oh, that could have been me. I have gone, I’ve gone through that path and the only thing that stopped was, oh, we had a two-nurse check,” or “I just got lucky and happened to, oh, wait, wait, wait, what, and caught it.” Or “I actually made a mistake like that, that actually,” I heard from one nurse who said it actually resulted in the death of a baby and “I went through this whole process and it was just the worst. It was so horrible and now I work in this aspect of nursing because I was so traumatized by that.” These are good people who make mistakes and a lot of the mistake burden is from the system.
So how do we respond in our typical American way? I’ll throw them in jail. It is going to disincentivize quality improvement. It’s gonna disincentivize honest reporting of mistakes. And it’s gonna allow hospitals to go, “Well, you know, if stuff goes south and our systems aren’t great, we can just throw the nurse under the bus and they can go to jail and we can just continue to, oh, we’ll make a few improvements here and there.” No, that’s not how it works. And after COVID, you think it’s easy to recruit people who wanna go into nursing? Do you think after this it’s gonna be easy to recruit people who wanna go into nursing? Nurses around the country are outraged, understandably. And I’ve heard from doctors who are like, “Man, if this is how they treat us, like criminalize this,” think what’s gonna happen. I mean, it’s absolutely horrible. And I’m not sure, you know, who the prosecutors are.
This is the crazy thing. On the jury were a nurse and a respiratory therapist. And I don’t know how unanimous the jury was, but I mean, clearly they’re hearing stuff that we’re not hearing to convict because I guess, legally, this is all correct. Like, by legal parameters, they convicted her of these charges. My point is those charges should never have been filed against a nurse for a medication error. That’s the point. And now we’re here. All right, I’m gonna look at your comments ’cause otherwise I’m just gonna get very un-alt-middle on this and get more angry. I’m pulling them up right now. And again, I did a piece on this in 2019 and I pretty much said this at the time and she wasn’t, you know, and they delayed her trial because of COVID.
Let me pop out the comments ’cause of course Facebook doesn’t work. Yeah, see, Martha says, “I am RaDonda.” We are all, everybody in healthcare is RaDonda. Like, yes, we occasionally get complacent, yes, and it just so happened that she got complacent at a time that it cost somebody’s life under torture. It’s horrible. How does she feel about it? Terrible. There’s something called a second victim scenario where you have the victim, the patient, and then you have the second victim, the caregiver.
The same thing happened when I talked about a nurse practitioner who accidentally left her baby child in a car as she went to work because her whole system, the Swiss cheese, had realigned where her husband usually takes the daughter to preschool. This day, she had to do it. She had a million patients on her schedule. She was super busy, distracted, on autopilot, went on autopilot. Instead of going to the preschool, she went to her work. The child fell asleep in the backseat so didn’t make a noise. She got out of the car, went did her job, came back eight hours later, and finds her child dead in the car. If you don’t think that can happen to you, you’re delusional, you’re blind. Human beings are human beings. That’s why we have systems in place. That’s why we have technology to try to help us.
Instead, what the hospital does is it puts in systems trying to build better and code better and they put all the burden of using those systems and inputting data on us and then they say, “Well, you better improve patient quality and satisfaction and you better not hurt anyone or else it’s your problem and you didn’t work hard enough and you didn’t, you know, check all the boxes.” That shit is wrong. It’s just wrong. Humans make mistakes, so we need systems to help us. We need society to help us. We need support. We don’t need criminal retribution for a nurse who made a fatal error.
Kim Milov says, “It could be anyone in healthcare, you or I.” I agree, could easily have been me. Ryan Cook said, “Did the state of Tennessee not look at Just Culture Algorithm? I have no idea what they did, Ryan. Once you file the charges and push it through, it’s like, you know… I don’t know what the criteria are for criminally negligent homicide. She didn’t get convicted of the highest charge, which was reckless homicide. So at least there’s that.
Jay Brooks says, “I’m an ICU nurse and get chills thinking about how this incident could have been me.” Every single one of us who works in healthcare is going, “Gah.” And I’ll tell you, the people who are like, “Oh, man, no, she was just absolutely incompetent and should go to jail and should, you know, get the death penalty or whatever,” ’cause I’ve heard some people say that, they’re just blind, in my opinion. They’re not able to inhabit a, and this is a very alt-middle thing, being able to inhabit the position of someone going through something. Like, we can all inhabit the position of this patient. We can inhabit the position of the patient’s family. It’s horrible. It’s inexcusable. It’s just terrible. So what do you do? You try to make the systems better. You do the best you can. And from my understanding of the case early on was that the family had already effectively said, “You know, we get it. It’s terrible. We’re very mad at Vanderbilt too because it wasn’t clear to us what was happening,” right?
Candace says, “I got written up so many times for not taking a lunch because I was yelled at for being red on my med pass, being in the red on my med pass.” You know, the amount of documentation and stuff, it’s like if you don’t provide the staffing and support and then you do something like this, if Vanderbilt doesn’t come out and say, “You know what? We’re doing everything we can to support patient safety and we’re gonna do this for our nurses now and we’re gonna do that so that this never happens again,” now who the hell wants to work for Vanderbilt after this? This could happen to you, right? I mean, how many times have you been a bit complacent when you’re driving and you could have hit and killed someone, right? And again, that’s a criminal thing. It’s potentially a criminal thing if that happens. But in healthcare, we have all these systems and support. So why aren’t we actually implementing them and using them?
Katie Collins says, “Absolutely not a single healthcare professional on the jury. They were all dismissed by prosecutors during selection from my understanding.” That was not my understanding, Katie. The latest news report I saw said there were these two on the jury, but I could be wrong. But you guys tell me.
Lynn says “You’re 100% right. 40 years of nursing. It could be me too. We’re so effing busy, NICU nurse.” It’s terrible. Anyway, so listen, if you guys have ideas for how to improve the safety, I mean, look, first of all, our technology is garbage, and this is the, here’s the best part, like it probably cost Vanderbilt a billion dollars or something ridiculous to implement Epic and these systems in their hospital and they’re rewarded with garbage. And who holds those systems accountable? Like should Judy Faulkner, the CEO of Epic, go to jail because she was part of the thread that ultimately linked, failed to link Epic to the med Pyxis that allowed the dispensing of, should have allowed Versed? Maybe she should go to jail. Maybe the CEO of Vanderbilt should go to jail for not overseeing safety processes and implementing Just Culture and not reporting to the authorities this event. No, that’ll never happen because money talks and nurses walk into prison apparently.
Now, what’s interesting is there’s a criminal charge for a doctor in Ohio for giving ridiculous amounts of fentanyl during, you know, when he makes a patient DNR. I mean, it’s effectively euthanasia, and he’s being criminally charged, I believe. I think, anyways. So we’ll see what happens there because that’s interesting because part of the discussion here is intent, when you go through the Just Culture Algorithm. Was there intent to be reckless or do something abnormal? Did RaDonda Vaught have intent to kill this patient? Clearly not. Did RaDonda Vaught have intent to be reckless? That’s hard to judge, but I’m gonna say probably not. Did that doctor have intent doing what he was doing giving like a thousand micrograms of fentanyl, which is like a, or 300, I forget what he was giving, IV and then the patient’s dead like 10 minutes later? Yeah, I think there’s intent there. I mean, again, it’s always difficult to judge, but it’s a different scenario. So then you go, “Well, okay, if there was intent and it’s illegal, then there’s criminal intent.” Well, then filing criminal charges seems to make more sense, doesn’t it? And that’s something that is in the Just Culture sort of paradigm. So I don’t know.
Dawn Hausel says it best, “Who the hell wants to work anywhere? It’s too scary.” As if, you know, malpractice threats for doctors isn’t bad enough, right? Like we’re all scared that our career could be ruined. We’re scared we’re gonna hurt someone already. I hate to say this guys, but most of us are pretty good people trying to do the right thing. We don’t wanna hurt anyone. We don’t wanna hurt your mom or your daughter or your baby. That’s the last thing we wanna do. Lauren says, “Vanderbilt should be held criminally liable.” I don’t know. I don’t know. Thank you for the stars, Karen Wood. “System error by Vandy. What is vec doing in a radiology area?” Daniel.
And Heather Bryson says, “This is why interoperability is so important. Standardization is needed.” Yes. You know why our healthcare systems, our technology, doesn’t talk to each other, these systems don’t talk to each other? Because they were never made to. There’s no incentive to do that. Epic has every incentive to create a walled garden like Apple where you don’t share data across different systems. And when, you know, the government said, “Oh, we want electronic healthcare records everywhere,” they didn’t mandate interoperability. And you know, now you have these different silos, these information silos. And they didn’t understand the effect on humans where now we get human silos where we’re DMing each other through these things. We’re not talking to each other. We’re not exchanging the standard information that actually allows for better patient care. It’s all these electronic silos. There’s other new errors that are introduced by electronic health record. Now, we can make those better. I’m not saying get rid of EHRs. I’m saying make them better. Make them serve us instead of we’re serving the technology. We’re technology enslaved. We should be technology empowered.
So anyways, that’s my take on this, guys. I don’t know. Every now and again, something like this, I wasn’t even planning to do a show today and I saw this come out and I was like, “I gotta talk about this.” Do me a favor, share the show if you want to. I don’t know how to support RaDonda, honestly, except to keep making noise. That’s the best we can do. If you’re an expert in the space or something, make noise publicly. Write an op-ed, do something, right? We need to advocate for systems change, for more support, for more staffing, for more resources, for more emotional resources for our staff after COVID, like we don’t have, you know, PTSD on the front lines. Come on, guys. We can do better. We have to do better. And, yeah, that’s it. Normally I make my pitch for become a Supporter and all that, but, you know, do what you like.
Just let’s have systems change, all right? I love you guys. We really have to do better. My heart goes out to Charlene Murphey’s family for all the suffering they’ve had to go through. My heart goes out to RaDonda Vaught and her family. Yeah, that’s all I have to say. All right, guys, I love you.
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