I believe Ms Vaught is charged with reckless homicide, a form of manslaughter in TN. Rather, I would like to highlight how you can hopefully avoid being in her shoes through a review of some medication administration principles that minimize the errors that reportedly occurred during her mistaken administration of the wrong medication. That is a big discrepancy that led to the error when the nurse is trying to find the medication. Too often, leaders assume that a catastrophic medication error that has happened in another facility will not happen in their facility. In particular to Vaughts case, the future of Americas most trusted profession for the past. of the case led to Vaught getting fired, Vaught losing her Tennessee nursing license, and an out-of-court settlement between the hospital and Murpheys family. The reality is that mere human error that randomly occurs in well-meaning people is now considered criminal in various circumstances where public safety is an issue. She mistakenly administered the powerful paralytic vecuronium instead, which led to total muscle paralysis and stopped Murpheys ability to breathe and caused her death. Nurse RaDonda Vaught faces criminal trial for medical error - NPR Five additional red flags were also ignored. It is inevitable that mistakes will happen, and systems will fail. I do believe that the criminal justice system has an important role in persecuting health care professionals for clear negligence, such as. According to documents filed in the case, Vaught initially tried to withdraw Versed from a cabinet by typing "VE" into its search function without realizing she should have been looking for its generic name, midazolam. Smith also described how the TBI, the Tennessee Department of Health and the Nashville district attorney's office met to discuss Vaught's case in January 2019, shortly before criminal charges were filed. Phone: 919-962-5106, The University of North Carolina at Chapel Hill, North Carolina Journal of Law & Technology, No nurse has ever been criminally charged, RaDonda Vaught accidentally gave Vecuronium instead, computerized medication dispensing machine, could impact virtually all aspects of health care law. When a patient dies as a result of an error, it is human nature to react to the egregiousness of the injury.7 Although we have a tendency to view errors leading to harm as more blameworthy and punishable than the same errors that do not lead to harm,17 allowing a severity bias to drive the response is not fair to the workforce and does not maximize safety. Prosecutors claimed that because she consciously disregarded warnings, she is culpable. Some legal experts have identified ways to reduce medication errors using the law as a tool. This question is associated with conscious disregard of a known risk, not conscious disregard of a policy, procedure, or safeguard. Policy, procedure, and safeguard deviations are often at-risk, rather than reckless, choices where the risk is not seen or mistakenly believed to be insignificant or justified.18 Most at-risk behaviors are caused by system failures that practitioners must work around, often on a daily basis, to get the job donesuch as obtaining a medication by override because it cant seem to be found in the patients profile. In the case of Vanderbilt hospital, their whole system failure and blatant disregard for safety, by telling the nurses to override meds without weighing the consequences., Vec should never be an overrideable medication. Protecting the system instead of the individual is wrongthe system should support the individual and not punish those who are honest about their errors. On March 25, she was convicted of gross neglect and negligent homicide in a patient's 2017 death. Honesty about mistakes helps address gaps in the system so that future mistakes can be prevented. Disclosing errors is never easyit can be humiliating and shamefulbut we should embrace each other and understand that medical jobs are incredibly taxing and mistakes are easy to make. What are the implications for health care and the law? Additionally, Vaught did recognize that vecuronium is powderized and needs to be put back into solution, whereas Versed is a liquid. Non-disclosure violates the ethical principles of autonomy by not informing patients of their care, non-maleficence by withholding information and further harming a patient after the initial error, and most significantly fidelity by compromising the patients trust in the medical system. Central to Vaughts reckless homicide charge is that she used the override function on the automated dispensing cabinet (ADC) to withdraw vecuronium (the paralytic) instead of the prescribed drug, Versed (the sedative). This is a medication that you should never, ever, be able to override to, Brown said. In nurse's trial, witness says hospital bears 'heavy' responsibility We personally thank all who show support of this nurse, as it is critical to her psychosocial and physical recovery. RaDonda Vaught admitted that she overrode the computers system to take out the Vecuronium, causing her not to realize that she had pulled out the wrong medication. In fact, the lesson that should be taken from this case is that a systems-based approach is the most effective way to prevent these types of errors. Also a position as such should have a nurse that is experience with. Two years after Vaughts error, Cohens organization documented a strikingly similar incident in which another nurse swapped Versed with another drug, verapamil, while using an override and searching with just the first few letters. Prior to a full body scan, IV Versed had been ordered as an anxiolytic due to the patients claustrophobia. Whether the nurse made an error in judgement when deciding to obtain the medication via override is not the issue; the real issue in this case is that there were no effective systems in place to prevent or detect the accidental selection, removal, and administration of a neuromuscular blocker that had been obtained via override. Or, leaders and others, including the criminal justice system, may overlook latent system failures that contributed to an error and instead focus only on the frontline nurses active failure to follow the five rights., Yes, RaDonda did not complete verification of the five rights, which is a failing with ANY medication error. "Vanderbilt University Medical Center? Having an oriented, a float nurse with only 2 yrs of experience being pulled all over the hospital. The case hinges on the nurses use of an electronic medication cabinet, a computerized device that dispenses a range of drugs. Accountability for safety must be shared, and leaders are ultimately responsible for system design as well as subsequent design changes that are needed to improve safety within their organizations. Incidentally, it appears that the patients family does not agree with the criminalindictment of RaDonda. Vaughts case, however, was re-investigated as a criminal case after an anonymous tip went to the Centers for Medicare & Medicaid Services and the Tennessee Department of Health. As a nurse faces prison for a deadly error, her colleagues worry: Could I be next. It can inhibit error reporting, contribute to a culture of blame, undermine the creation of a culture of safety, accelerate the exodus of practitioners from clinical practice, exacerbate the shortage of healthcare providers, perpetuate the myth that perfect performance is achievable, and impede system improvements.11 For example, if an error happens when retrieving a medication via override, why would it ever be reported if the practitioner could be charged with a crime and it can easily be hidden? . RaDonda Vaught has also spoken out, revealing that she understands this case is about far more than just her culpability. On Friday March 25, 2022, former nurse RaDonda Vaught was found guilty of criminally negligent homicide and gross neglect of an impaired adult. And the second kind are the ones who know this could happen, any day, no matter how careful they are. She mistakenly administered the powerful paralytic vecuronium instead, which led to total muscle paralysis and stopped Murpheys ability to breathe and caused her death. Clearly, the error that led to the criminal indictment of RaDonda could happen in almost any hospital that uses ADCs given the need for override functionality. However, blame in and of itself does no one any good. Michael Cohen, president emeritus of the Institute for Safe Medication Practices, and Lorie Brown, past president of the American Association of Nurse Attorneys, each said it is common for nurses to use an override to obtain medication in a hospital. Fatal errors are generally handled by licensing boards and civil courts. More than $50,000 was raised within the first 4 days of setting up the GoFundMe campaign, and the outpouring of emotional support, particularly from nurses, has been phenomenal. As a nurse faces prison for a deadly error, her colleagues worry: Could Vanderbilt scapegoated RaDonda Vaught for 'systemic errors,' attorney says Nurse sentenced to three years probation in fatal drug error : Shots CE that meets your needs. You have a legal and ethical obligation to adhere to standards of practice and standards of care applicable to your role in the process of medicine administration. The patient was supposed to get Versed, a sedative intended to calm her before being scanned in a large, MRI-like machine. In response to a story like this one, there are two kinds of nurses, Garner said. Vaught is on trial for the death of Charlene Murphey, a 75-year-old Vanderbilt patient who died on Dec. 27, 2017, after she was prescribed a sedative, Versed, but was inadvertently injected with a powerful paralyzer, vecuronium. Ex-nurse found guilty of criminally negligent homicide in medication With this technology being used for medication distribution in more than 80% of hospitals and health systems, ISMP believes organizations have an obligation to ensure that the implementation of ADCs and the management of ADC overrides are optimized in a manner that promotes safe patient outcomes. Moreover, she overrode five warnings that the medicine she was withdrawing was a paralyzing agent. I work in a health care system. Vaughts sentencing will be held on May 13. Safety experts and many licensing boards agree that the criminal system need only be invoked in rare cases when harm is purposeful or knowingly caused without a justifiable benefit. The latter topic includes a focus on managing system overrides safely. This verdict is tied to a medication error that Vaught made in 2017 while working at Vanderbilt University Medical Center, which ultimately resulted in the patient's death. When the cabinet did not produce Versed, Vaught triggered an override that unlocked a much larger swath of medications, then searched for VE again. Although the health department did not try to fine or sanction Vanderbilt, it did punish Vaught. Nor can we repeatedly engage in risky choices, then unjustly punish the unlucky few who have been involved in events that resulted in significant harm.7Avoiding the severity bias and establishing a Just Culture is paramount to safety. hide caption. Vaught was cooperative and honest about her mistake, this behavior should be rewarded instead of condemned. She also states that she recognizes the importance that her verdict has a much larger impact on health care as a whole: I have not shied away from my responsibility but health care is a system. Leaders must be proactive withsystem design improvements by learning and benefiting from the lessons learned by others when medication errors happen. Institute for Technology, Ethics, and Culture, Ethical Considerations for COVID-19 Vaccination, Hackworth Fellowships Project Showcase 2021, The Ethics of Going Back to School in a Pandemic, Systemic Racism, Police Brutality, and the Killing of George Floyd, COVID-19: Ethics, Health and Moving Forward, The Ethical Implications of Mass Shootings, Political Speech in the Age of Social Media, Point/Counterpoint: Democratic Legitimacy, Brett Kavanaugh and the Ethics of the Supreme Court Confirmation Process, Criminal Conviction of RaDonda Vaught sets Dangerous Precedent in Reporting Medical Errors. In 2017, a 75-year-old woman had a radiological procedure scheduled which required her to receive a dose of a sedative called Versed to keep her calm during the procedure. Our support for RaDonda in no way lessens our condolences to the patients family or minimizes the pain her family will forever bear from losing a loved one to a medical error. Despite obvious signs of a systematic failure leading to unsafe conditions, only Vaught is at the center of punishment for this accidental death. Please preserve the hyperlinks in the story. She was to do a Swallow study next. The case of RaDonda Vaught highlights a double standard for nurses and physicians. Central to Vaughts reckless homicide charge is that she used the. Caring for our own: deploying a systemwide second victim rapid response team. In fact, we find it shameful that a nurse who is already suffering and paying the price for her error is now facing a criminal indictment and possible trial, loss of her nursing license and livelihood, and time in prison. "There was no discipline because, according to [a Department of Health lawyer], a malpractice error has to be gross negligence before they can discipline for it.". KHN is an editorially independent program of KFF (Kaiser Family Foundation). Smetzer J, Baker C, Byrne FD, Cohen MR. Shaping systems for better behavioral choices: lessons learned from a fatal medication error. Stephanie Amador/AP After the conviction of former registered nurse RaDonda Vaught, following a fatal medication error, the Institute for Safe Medication Practices (ISMP) asserts that the verdict was unfair and warns about the negative impact on the entire healthcare community. You have the nurses who assume they would never make a mistake like that, and usually its because they dont realize they could. In almost every clinical setting, nurses access medications through a computerized medication dispensing machine that generate error messages or warnings for certain risky medications, and they often require verification by a pharmacist before they can be taken out for a certain patient. It is understandable that Vaughts conviction makes healthcare professionals very worried and may incentivize them to cover-up medical errors instead of reporting them. RaDonda Vaught, 38, was indicted in 2019 on two charges, reckless homicide and impaired adult abuse, in the death of Charlene Murphey at VUMC. At that meeting, it became clear the Department of Health had determined that Vanderbilt had a significant role in the death, Smith said on the stand, reading a meeting summary from an internal report she wrote. Vanderbilt University Medical Center has repeatedly declined to comment on Vaughts trial or its procedures. When the cabinet did not produce Versed, Vaught triggered an override that unlocked a much larger swath of medications and then searched for "VE" again. It is commonly given to patients prior to intubation (where the doctor inserts a breathing tube) or when they are on a ventilator so that the machine can do the breathing for them. Click the button below to go to KFFs donation page which will provide more information and FAQs. We know that when nurses work longer shifts, there is more room for errors. I could be RaDonda.. They found a seat.". Former nurse guilty of homicide in medication error death - EMS1 We cannot wait for harm to address risky systems or behaviors. Vaught has admitted her role in the fatal drug mix-up, but she insists the error was possible only because of technical problems and flawed procedures in place at Vanderbilt at the time. While our legal system allows for the criminalization of human error even in the absence of any intent to cause harm (see Sidebar 2), ISMP does NOT believe criminal charges are justified in this case. If you are lucky, the patient is unharmed. The timing of this case is especially concerning because of the heightened stress in health care systems from national nursing shortages and two exhausting years of the pandemic. Lesson from the Denver medication error/criminal negligence case: look beyond blaming individuals. Ex-Tennessee nurse RaDonda Vaught sentenced to probation in patient For those unlucky enough to make one of these errors, criminal charges may only be an indictment away.7. She is interested in a career in health law. RaDonda Vaught, a former Vanderbilt University Medical Center nurse charged with the death of a patient, listens to the opening statements during her trial. Are you looking for a new way to recruit nurses for your open positions? RaDonda Vaught, charged with reckless homicide, arrives for a court hearing on February 20, .