After a long day of work, I was scrolling through my newsfeed on Facebook before bed (horrible habit, I know) and stumbled across the story of RaDonda Vaught. Maybe you’re familiar with her, maybe you’re not. In case you’re not, here’s the exact video that piqued my interest by Z Dogg, MD, a video/blogger physician:
I’ll break it down for you too:
75-year-old Charlene Murphey was admitted to Vanderbilt University Medical Center in Nashville, Tennessee, on December 24th, 2017 after suffering vision loss and finding that she suffered a subdural hematoma (brain bleed). A few days into her stay, on December 26th, 2017, she was scheduled for a “full body scan” (the CMS report states it was a PET scan). Charlene reported that she was claustrophobic, so her physician wrote from 2mg of Versed (midazolam), an anti-anxiety medication. Vaught was working that day. A nurse called her to take a medication to a patient in PET scan. Vaught could not find the medication in the medication dispensing machine (called an ADC), overrode the machine, typed in “VE” and selected the first medication. She drew up the medication, gave a milliliter, and left radiology. After the scan was done, the Charlene was found pulseless, and a code was called. She was revived after 2-3 rounds of CPR but died several days later due to brain damage.
Sadly, it was not from natural causes. The first “VE” medication that came up when Vaught typed in the machine was vecuronium, a paralyzing agent usually used in surgeries and intubations. Vaught unwittingly gave the wrong medication, causing Charlene’s death.
But a series of other events happened as well. The patient was immediately placed in the scanner and left alone for 30 minutes. The patient went unmonitored to and in PET scan. Vaught had access to vecuronium in a normal medication dispensing machine.
From what I have read about this case, a lot of commentary is around the fact that the patient was not monitored in the PET scan. However, from what I am reading in the CMS report, it appears that at the highest level of care, Charlene was on a step-down unit. Transport had taken her to PET scan, and transport only take non-monitored patients. If that was the case, the patient was allowed to go off the floor without monitoring, so it is not Vaught’s fault she was not monitored.
Too, Vaught was not the primary nurse. From what is described in the CMS report, she was the “help all nurse” who tasks for other nurses. It sounds like she was going throughout the whole hospital. My hospital calls it a resource nurse. I’ve done it for my department. Another nurse tells you a patient needs something, and you do it. The information you receive is extremely limited. The primary nurse was covering yet another nurse’s lunch when radiology called about Charlene, so it was unrealistic for that nurse to go. I guarantee nurses at my hospital call the resource nurses to do similar daily.
Vaught needed to override the medication machine to get what she needed. The day I stumbled across the video, I had done it at least 2-3 times that day. It’s a common thing to do if a medication is not popping up in the machine like it should. It takes a loooooong time to fix technology issues sometimes there is no time to wait.
Vaught was also training someone and was teaching him/her while drawing from the medication machine. I once read that most medication errors happen when the nurse is distracted when getting and drawing up the medication. One hospital I worked at had stop signs in the medication room to remind people to concencrate. But I can also tell you that people still talked. I catch up with a co-worker while at the medication machine all the time. Sometimes it’s the only time I see a given person in a given day. And it’s a rare time away from patients, so talk at the med machine happens all the time.
What is most interesting to me is that state officials found no reason to discipline Vaught or limit her license, noting that they found no intent to harm. Reading through the CMS report, Vaught did everything one is trained to do after a medical error. She owned up to it. She filled out a safety event. She spoke to managers, educators, and risk management. This was a simple but devastating medication error.
So why is it a criminal case? And why was she fired?
Medication errors are common. Very common. My last one was 6 months ago when my bedside computer was not working and I could not double check the dose of the medication I was giving. I gave a double dose of a scheduled medication. That’s not my first, and it won’t be my last. I once gave a clot-busting medication instead of a medication for blood pressure because I was rushed and not paying close enough attention. The patient was fine, but I was shook. The feeling of dread was awful. I sprinted to the room to make sure the patient was OK. He was.
Every nurse has committed a medication error. Mistakes happen in any human endeavor, but medication errors are scary because someone’s life is at risk for your mistake. I have never heard of a nurse being fired for a medication error. Even a nurse on my unit who hung an antibiotic on a wrong patient who also never looked at a computer or wristband and who also has a record of making mistakes has not been let go. Mistakes happen, and it is hard to fire someone without establishing that an error is part of a larger pattern of behavior.
The American Nurses Association in commenting on Vaught’s case wrote: “The Code of Ethics for Nurses states that while ensuring that nurses are held accountable for individual practice, errors should be corrected or remediated, and disciplinary action taken only if warranted. When error occurs, whether it is one’s own or that of a coworker, nurses may neither participate in, nor condone through silence, any attempts to conceal the error.”
Like Vaught, I did not conceal my errors. I have never received disciplinary action for medications errors because they are a mistake and not a pattern of behavior. It sounds like Vaught was not a nurse who had a bad pattern of behavior. From the commentary, it seems that she is well loved and respected. I think she was unjustly let go. She did everything she could after realizing she made a mistake.
So, again, why is it a criminal case?
Legally, it can be a crime to harm someone to the point of death by an error even when no ill will or intent is identified. According to an article on the Institute for Safe Medical Practices (ISMP) website, the District Attorney’s Office is using the fact that Vaught used an override in the medication dispenser as grounds for their case.
But as they wrote, “The override feature is available in basically every hospital that utilizes ADCs and is a function used every day to obtain specific medications when a delay in treatment could impact patient care. Most often, these are emergent or urgent medications. However, the override feature may also be necessary for other medications and solutions in facilities that do not provide 24-hour pharmacy services.” (Or during downtimes, which are always unscheduled on the shift I work. I had Again, a commonplace thing!)
However, it is not unheard of that nurses have been criminally charged in wrong death suit.
In 2007, nurse Julie Thao was charged with a felony for criminal neglect when she administered an epidural medication IV to a 16-year-old on a labor and delivery unit. The patient died. Thao eventually pleaded guilty to two misdemeanor charges and was given 3 years of probation. The state board of nursing suspended her license for 9 months and restricted the hours she could work (no more than 12 hours in a 24-hour period or more than 60 hours per week for 2 years). As part of her probation, she could not work on a critical care unit or labor and delivery unit.
I have known about the Thao case for years because it happened in Madison, Wisconsin, which is where I went to nursing school.
But look at those hour restrictions! Why should anyone be forced to work that? Yet nurses are forced to work 16 hour shifts, which is what Thao was working when she committed the mistake. Many local hospitals in my area had mandated overtime, so they are poorly paid for the extra hours too. But that’s what nurses are forced to work. People may look at my schedule and say, “dang, that’s easy.” However, the workload is exhausting.
Look at the circumstances around Vaught needing to go administer a medication in PET scan! Why was staffing so short that a nurse who knew nothing about the patient had to go down to scan? Why was there no monitoring equipment for her down there? Why was there no medication scanner there? Why was the video monitoring quality so poor that the radiology technician could not see that the patient had stopped breathing? Why did the doctor not anticipate the patient’s claustrophobia so the medication could have been given in the unit with a scanner?
The issue with criminalizing medication errors is that is fails to take into account all the little errors that lead to the fatal one. It’s called the Swiss Cheese Model, which was created by James Reason and Dr. Charles Vincent. It’s so well known in health care that it is taught almost everywhere and is even on the AHRQ website.
So, if it takes a system to make a mistake, where is everyone else in Vaught’s case? Where is the primary nurse that said that the patient could go unmonitored? Where is the physician who said that the patient could go unmonitored? Where is the radiology technician who did not identify that the patient stopped breathing but did note that her eyelids were shut? Where is the IT guy who is in charge of the medication dispensing machines? What about hospital leadership? What about the architect who designed a hospital when inpatient units are so far away from radiology?
Vaught is the final slice of cheese. A series of errors lead to the death of Charlene, not just Vaught’s mistake. It does not make sense to blame one slice of cheese, especially in this case where Medicare threatened to not give reimbursement to Vanderbilt because it did not see the hospital take appropriate action after the deadly error.
And what is frightening is that I am that last slice of cheese. There is an enormous amount of pressure to never make a mistake because I am the last line of defense before something happens to a patient. But it takes a series of unfortunate events for a mistake to reach a patient. Sadly, as a nurse who fills out safety events on the regular, it is hard to make hospital administrators care unless that happens. So, why blame the last slice of cheese?
In essence, these are my thoughts:
- This is a tragic case, and I do not think criminalizing the mistake does any good. Medicine already has a problem admitting it does wrong, and cases like this just make the secrecy worse.
- The family of the patient who passed away does not even want to pursue legal action and has offered Vaught forgiveness. Where is the motivation in criminally charging her?
- I hope that this case is thrown out and that Vaught is able to return to work.
- I hope it sets a legal precedence in that an honest medical error is not a crime.
If anyone is interested in supporting Vaught for her legal team, her GoFundMe site is here.