“COVID-19 has already exhausted and overwhelmed the nursing workforce to a breaking point. Nurses are watching this case and are rightfully concerned that it will set a dangerous precedent.” — The American Nurses Association
One of my good friends is a nurse, and he was telling me about a case where a nurse at Vanderbilt was convicted and arrested for making an unintentional mistake. He seemed to disapprove of the verdict, and I got the sense that every nurse makes mistakes, but this verdict sent a message to nurses around the country: watch out — it could happen to you too.
Whether this is true or not true remains to be seen. All over the Internet, the term “chilling effect” is being used to describe the effect the verdict will have on nurses. The chilling effect usually refers to not feeling like you can speak freely in line with the First Amendment, but in this case, it refers to nurses having to watch their backs and not reporting mistakes.
To me, it seems easy for nurses to occasionally make mistakes, although I understand the pushback that comes when the mistakes are lethal with severe repercussions. Nurses often have to work 12-hour shifts, through night shifts, and deal with unreasonable demands.
They’re also human.
The nursing shortage has grown substantially worse over the course of the pandemic — according to Tony Yang and Diana Mason at Health Affairs, 92 percent of critical care nurses said the pandemic “depleted nurses at their hospitals, and, as a result, their careers will be shorter than they intended,” and 66% are considering leaving the professions. Across the country, nurses are struggling with burnout and exhaustion which might make mistakes easier to make.
The case in question was that of 38-year-old RaDonda Vaught, a former nurse at the Vanderbilt University Medical Center (VUMC) who was found guilty of criminally negligent homicide and gross neglect of an impaired adult, as noted by Katherine Oung at the Vanderbilt Hustler. Vanderbilt was not found guilty of reckless homicide.
This case and trial are unprecedented in the nursing profession. According to Brett Kelman at NPR, health care workers rarely face jail time for unintentional medical errors. Instead, these medical errors are usually handled by licensing boards and civil courts.
Why was RaDonda Vaught convicted?
In 2017, Vaught was treating a 75-year-old patient admitted to the VUMC with a bleed in her brain, Charlene Murphy. Due to Murphy’s claustrophobia, she had to be administered a sedative intravenously to prepare for a PET scan, Versed.
Mariah Timms at the Tennessean notes Vaught was working in the intensive care unit of the VUMC, and Vaught typed “VE” into an electronic medication cabinet that dispenses drugs. Court documents say the cabinet did not produce Versed, so Vaught triggered an override system that unlocked more medications.
She typed “VE” again, and the system gave Murphy a drug called vecuronium instead of Versed. Vecuronium is a paralytic drug, not a sedative, and Murphey was left unable to breathe and died soon after being given vecuronium.
Prosecutors, during Vaught’s trial, said Vaught made at least 10 different mistakes that led to the death of Murphey. One of the mistakes was a bold warning that said: “WARNING: PARALYZING AGENT” on the cap of the medication. Since Vaught would have had to look directly at the warning when putting a syringe at the bottle, prosecutors argued that Vaught overlooked this warning.
Vaught said she was “distracted” by a conversation with a colleague, and prosecutors also said Vaught overlooked a safeguard on a cabinet — vecuronium is used to treat an emergency, and she was not treating an emergency.
According to prosecutors, Vaught overlooked this safeguard and also ignored four warnings about the medication she was using. Another factor Vaught overlooked was the drug was supposed to be liquid, but the drug she used was a powder and had to be mixed with liquid before being given to patients. Vaught then did not monitor the Murphey for 30 minutes after administering the drug, violating a mandated observation protocol.
The charges and trial
A Tennessee Bureau of Investigation report revealed Vaught’s side of the story. Vaught said the medication being powder “struck her as odd” and she didn’t see the warning label, even though she acknowledged she “should have recognized the difference.” She admitted thinking “I probably just killed this patient.”
The criminal charges for Vaught’s mistake escalated during a federal investigation from the Center of Medicare and Medicaid Services (CMS) into the VUMC.
On December 27, 2017, medical examiner records from neurologists say Murphey died from “natural causes of complications of the intra-cerebral hemorrhage.” It stated there was “no foul play suspected.”
The VUMC, however, decided to fire Vaught in January 2018 after an internal investigation. . Vanderbilt made an out-of-court settlement with Murphey’s family that prohibited Murphey’s family from speaking publicly about her death.
However, the CMS investigated VUMC in November 2018 after receiving an anonymous tip. On November 19, 2018, Oung notes the CMS published a public report, a report that condemned the VUMC for not reporting the medication error as mandated by the Health Data Reporting Act.
Above all, the report threatened to cut 22% of Vanderbilt’s Medicare reimbursement funds. VUMC proposed not to take corrective action, like shrink-wrapping medications that could paralyze people and adding more warnings to the electronic system.
Then, the Davidson County District Attorney’s Office started its own investigation and brought an indictment against Vaught in 2019 for reckless homicide and gross neglect of an impaired adult. Dozens of nurses from out of state came to Tennessee to support Vaught.
In 2021, Vaught’s nursing license was revoked. During the trial, Vaught’s defense attorney blamed her mistake on “systemic problems” at VUMC.
Ultimately, the jury found Vaught guilty of criminally negligent homicide on March 25, 2022. Vaught will be sentenced on May 13, 2022, and can face up to six years in prison. The Nashville District Attorney’s Office defended the decision and said:
“The jury’s conviction of Radonda Vaught was not an indictment against the nursing profession or the medical community. This case was, and always has been about the gross neglect by Radonda Vaught that caused the death of Charlene Murphey.”
The precedent set by the Vaught verdict
“This is a gross miscarriage of justice and should immediately be reversed — whether through judicial review or pardon,” Dr. Michael Brisman, CEO of NSPC Brain and Spine Surgery said.
After the Vaught verdict, there has been tremendous backlash from members of the medical and nursing community, particularly in a joint statement from the American Nurses Association (ANA) and the Tennessee Nurses Association (TNA). They said criminalizing medical errors would have a “chilling effect” on the reporting process, and the criminalization of Vaught’s mistake is not in line with the Code of Ethics of Nurses.
One Knoxville nurse, Tina Vinsant, told WKRN that the ruling will set a negative precedent.
Right now, there is a petition on Change.org urging clemency for Vaught, saying Vaught had been honest the entire time and reported the incident as she should have. Other nurses who have worked with her have attested to her “character, compassion, professionalism and skills.”
It currently has over 209,000 signatures with a goal of 300,000.
Was Vaught thrown under the bus after CMS threatened to cut VUMC’s funds? Was she thrown under the bus to protect Vanderbilt’s respected reputation?
Her defense attorney, Peter Strianse, seems to think so:
“We are engaged in a pretty high-stakes game of musical chairs and blame-shifting. And when the music stopped abruptly, there was no chair for RaDonda Vaught…Vanderbilt University Medical Center? They found a seat.”
While Vanderbilt was required by law to report the medical error to state and federal regulators, they did not, as evidenced by medical examiner records. One TBI special agent said Vanderbilt did not accurately document the cause of death, and that Vanderbilt played a significant role in Murphey’s death.
As a teacher, I am also in a female-dominated and historically underappreciated profession. Teachers make a million mistakes every day and deal with constant moral ambiguity, but the difference is it’s not life and death when a teacher makes a mistake.
Medical errors are, by nature, incredibly costly.
Vaught was also not the only nurse in the VUMC system to use the override system, as she testified and other Vanderbilt nurses corroborated. Using the override system was often used to get through delays.
Beyond Vaught’s mistake, medical professionals worry the criminal charges and indictment send the message to medical professionals, and nurses particularly, that accurately and honestly reporting medical errors can get you arrested, or even be incriminating yourself.
Vaught said she doesn’t work in a vacuum. She works in an entire system, and she doesn’t regret being honest about her medical error. However, the message is clear to many other nurses: being honest about your medical errors might lead to you going to jail or being punished.
Many other nurses are less likely to report errors truthfully as a result, which will inevitably worsen safety in healthcare than improve it. By criminally charging Vaught, we are pushing the blame for medical errors on an individual nurse over the institutional issues in the entire healthcare system.
At the end of the day, Vaught reported her error — Vanderbilt did not.
But during a pandemic, unprecedented staffing issues, shortages, and burnout, many nurses, according to Brett Kelman and Hannah Norman at NPR, are wondering “am I next?”
It’s clear everyone understands Vaught’s mistake was not intentional. But it’s clear to also acknowledge the counterargument that a 75-year-old woman died as a result of Vaught’s mistake.
Not every nurse agrees that Vaught shouldn’t have been charged criminally, and Murphey’s family “forgave” Vaught in 2019, but has supported the prosecution and has decried people using the death of Charlene Murphey for “personal gain.” A jury of 12 people still found her guilty beyond a reasonable doubt, and the more information the prosecution revealed, the more evidence the jury found of her guilt.
When we criticize systemic failures, it’s important not to deny individual agency, either. Yes, nurses and medical professionals occasionally make mistakes. But the counterargument against the “RaDonda Vaught shouldn’t have been criminally charged” and “it could have been any nurse” narrative is Vaught made a lot of egregious mistakes that go beyond being attributed to exhaustion, burnout, and fatigue.
Nurse and nurse educator Kati Kleber, however, urges Vanderbilt to also be held accountable for a failure to report, and also be charged criminally.
Regardless, for nurses around the country, this is much more than just one isolated case of a nurse making sloppy mistakes — it’s about a shift in the nursing profession and healthcare as a whole.
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This post was previously published on MEDIUM.COM.
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