By Kendyl Brower
In 2017, Nashville nurse RaDonda Vaught withdrew a paralytic drug rather than a sedative and administered it to a patient. Vaught entered VE into the automated medication cabinet and withdrew vecuronium, a deadly paralyzer, instead of Versed. This medical error left 75-year-old patient Charlene Murphey brain dead. Immediately, Vaught admitted her mistake to her peers. Two Vanderbilt neurologists reported the death to the County Medical Examiner, citing the death as “natural” and thus, the error was not investigated. Vanderbilt officials did not report the mistake, though it is required by law. The Vanderbilt University Medical Center (VUMS) fired Vaught and negotiated a settlement with the Murphey family. Like most cases of medical errors, the Board of Nursing revoked her RN license, effectively ending her nursing career. The Tennessee Department of Health, the institution responsible for investigating medical professionals, stated that the case “did not constitute a violation” and no further action was necessary. Vaught’s story, however, does not end here: on March 25, the 38-year-old nurse was convicted of negligent homicide and felony abuse of an impaired adult and now faces eight years in prison.
Upon a surprise investigation, the Center of Medicare and Medicaid Services (CMS) inspected the incident and found that Vanderbilt did not report the error to the government. CMS threatened to suspend payments to Vanderbilt unless the hospital demonstrated a plan of correction to prevent future errors. Thus, the hospital sent a “plan of correction” to appease the agency. The Tennessee Department of Health pursues discipline against Vaught despite their prior decision, leaving Vaught with heavy fines on top of her license revocation and criminal charges.
Ronda Vaught is at fault for the death of Charlene Murphey, but she is not alone. The practices of the VUMS are equal contributors to the error: why was there no failsafe? Why is it not required to monitor a patient after a dosage of Versed? Why was it so easy to access vecuronium? Yet, a singular worker who already endures burdening consequences—her nursing career destroyed—faces jail time while the institution walks off with no legal punishment. There is no justice in criminalizing a worker’s error without addressing the institution that is equally to blame. Vaught admitted her mistakes, stating, “There won’t ever be a day that goes by that I don’t think about what I did,” which is a direct contrast to the lack of transparency of VUMS. The medical center not only failed to report the error but delayed the investigation entirely. Vaught was scapegoated by a center that is understaffed, underfunded, and reliant on malfunctioning equipment. Peter Strianse, Vaught’s criminal defense attorney, notes, “There are some real systemic problems with the way they dispense medicine through that automatic dispensing system.”
The Vaught case sets a dangerous precedent for health workers nationally. Medical errors are often dealt with in civil court, yet, now it is clear that such mistakes can lead to criminal charges. How can workers safely report their errors without fearing their fate? In any industry run by people, there will be mistakes. It is especially imperative to admit these faults in a timely manner in a hospital, where transparency is most essential. Medical errors should not be criminalized to preserve the integrity of self-reporting—The American Nurses Association and the National Medical Association both agree that the conviction sets a harmful precedent, and a whirlwind of fear and fury has struck nurses nationally.
It is crucial to hold people accountable for their wrongdoings but to criminally charge a nurse who had no intention to harm a patient is unjust. As we see time and time again, American workers are thrown under the bus, forced to pay for a mishap while the institution faces no repercussions.