The moment nurse RaDonda Vaught realized she had given a patient the wrong medicine, she rushed to doctors working to revive Charlene Murphey, 75, and told them what she had done. Within hours, she made a full report of her mistake to Vanderbilt University Medical Center.
Murphey died the following day, December 27, 2017. On Friday,of criminally negligent homicide and gross negligence.
This verdict – and the fact that Vaught has been charged – worries patient safety and nursing groups who have worked for years to move the hospital culture away from cover-ups, blame and punishment, and towards honest reporting of mistakes. .
The move to a “just culture” aims to improve safety by analyzing human errors and making systemic changes to prevent them from happening again. And that can’t happen if providers think they might go to jail, they say.
“The criminalization of medical errors is baffling, and this verdict sets a dangerous precedent,” the American Nurses Association said. “The delivery of health care is very complex. It is inevitable that mistakes will happen. … It is completely unrealistic to think otherwise.”
Just Culture has been widely embraced in hospitals since a 1999 report by the National Academy of Medicine estimated that at least 98,000 people could die each year due to medical errors.
But such poor outcomes remain stubbornly common, with too many hospital staff believing that acknowledging mistakes will expose them to punishment, according to a 2018 study published in the American Journal of Medical Quality.
More than 46,000 death certificates listed complications of medical and surgical care — a category that includes medical errors — among the causes of death in 2020, according to the Centers for Disease Control and Prevention’s National Center for Health Statistics.
“Best estimates are 7,000 to 10,000 fatal medication errors per year. Are we going to lock them up? Who’s going to replace them?” said Bruce Lambert, patient safety expert and director of the Center for Communication and Health at Northwestern University.
“If you think RaDonda Vaught is criminally negligent, you just don’t know how healthcare works,” Lambert said.
Murphey was admitted to the neurological intensive care unit on December 24, 2017, after suffering a cerebral hemorrhage. Two days later, doctors ordered a PET scan. Murphey was claustrophobic and was prescribed Versed for his anxiety, according to reports. When Vaught couldn’t find Versed in a vending medicine cabinet, she used an override and accidentally grabbed the paralyzing drug vecuronium instead.
Such errors often result in malpractice suits, but criminal prosecutions are rare. After Vaught was indicted in 2019, the Institute for Safe Medical Practices released a statement saying it had “worrying implications for safety”.
“In a time when we need more transparency, cover-ups will rule because of fear,” the statement said. “Even if mistakes are pointed out, effective investigation and learning about events cannot occur in a culture of fear or blame.”
Many nurses are “already at their breaking point … after two physically, mentally and emotionally exhausting years caring for patients with COVID,” said Liz Stokes, director of the Center for Ethics and Human Rights at American Nurses. Association. Vaught’s lawsuit gives them all the more reason to quit, she said.
“That could be me. I’m also a registered nurse,” she said. “It could be any of us.”
Vaught was steeped in the idea of Just Culture and says she has “no regrets” for telling the truth, but her outspokenness was used against her at trial.
When asked after the verdict, Vaught said she was relieved to have a resolution after 4½ years and hopes Murphey’s family will be relieved as well.
“Ms. Murphey’s family is at the forefront of my thoughts every day,” she said. “You don’t do something that impacts a family like this, that impacts a life, and carry that burden with you.”
Assistant District Attorney Brittani Flatt quoted her interview with a Tennessee Bureau of Investigation agent in her closing arguments: “I definitely should have been more careful. I should have called the pharmacy. I shouldn’t have canceled because it wasn’t an emergency.”
It’s easy to judge Vaught’s actions in retrospect, Lambert said, but waivers and workarounds are an extremely common part of healthcare, he said: “It’s typical behavior, not aberrant or weird.”
Meanwhile, Vaught’s honesty about his mistake has already resulted in safety improvements, and not just at Vanderbilt. Because vecuronium should only be used on patients who have inserted a breathing tube, some hospitals have removed it and other paralytic drugs from vending cabinets.
“At my hospital they changed their policy and put paralytics in a rapid intubation kit because of this,” said Janie Harvey Garner, who founded the nurse advocacy organization Show Me Your Stethoscope. She said that because Vaught recognized the error, Murphey’s death “probably saved lives”.
While Murphey’s death may serve as a cautionary tale for other nurses, Vaught, who is now awaiting a sentence of up to eight years, told The Associated Press in an interview that she thinks of her patient every days.
Vaught, 37, discovered that she and Murphey lived in the same small community of Bethpage, about an hour northeast of Nashville, and that she and Murphey’s family members had mutual friends. It would only be a matter of time before she met one of them in person.
“I imagined so many times how I would feel if it was my grandmother, a relative, my husband,” she said.
Recently, while shopping for farm supplies, she was talking with the young man behind the counter when he recognized her and told her he was Murphey’s grandson. Instead of scolding her, he ended up comforting her and patting her on the shoulder, she says.
“He was so nice. He was so incredibly nice,” Vaught said. “I took his grandmother and he kept telling me to take care of myself. There are good people in this world.”