A Nurses Review of the Vanderbilt Case
When nurses graduate and begin the dynamics of caring for a group of patients, they face multiple anxieties. Will I be able to rescue a patient when complications arise, they wonder? Will I know appropriate answers when physicians ask questions about patients in my care? And most importantly, will I make mistakes? Mistakes, especially medication errors, concern nurses throughout a career. In fact, it has been estimated by the FDA (and reported by AARP) that approximately 1.3 million consumers are injured by medication errors in the United States per annum, so nurses are correct to be concerned. No one wants to be responsible for potentially harming a patient.
Responsible nurses learn to follow policies and procedures that are designed to minimize the risk for errors. They rigorously adhere to the Five Rights when dispensing patient medication, or more recently, the 10 rights, which include five additional unratified responses * suggested by nursing experts:
- Right Patient
- Right medication
- Right dose
- Right route
- Right time
- Right patient education*
- Right documentation*
- Right to refuse*
- Right assessment (including possible contraindications) *
- Right evaluation*
However, no healthcare system, no matter how perfectly designed or executed, eliminates all risk, especially when utilized in an imperfect establishment: a hospital with a steady confluence of arrivals, departures, and emergencies in-between. Workarounds and shortcuts will be established, many by necessity (e.g. an Emergency patient), others by nurses who have become somewhat lax in following the rules. What you’re about to read is a true story of a nurse who missed several opportunities to halt a fatal medication error from materializing with a viable patient who was recovering from a subdural hematoma at Vanderbilt University Medical Center in Nashville, Tennessee.
When nursing colleagues learned RaDonda Vaught (a 35-year-old float RN) had been charged with reckless homicide and elder abuse early in February of 2019, shock ensued. A felony arrest following a medication error! Wasn’t this beyond the usual response of a Just Culture that has been promoted by Nursing Leadership to improve patient safety and avoid a punitive environment, especially since the publication of the IOM’s report To Err is Human, printed in the year 2000? Would this arrest encourage nurses to suppress future errors in fear of accusations or reprisals?
As RaDonda Vaught appeared in court February 20th, 2019 to plead “not guilty” (accompanied by her attorney) she was surrounded by a small group of nursing colleagues, wearing colorful scrubs and appearing in support of her cause. Not present at her court appearance was representation from nursing leadership. As revealed through early sound bites when RaDonda appeared in front of the media, she had a lot to say, but what she was saying wasn’t always in defense of great nursing process. Had nurse RaDonda somehow lost her way? She might have forgotten good practice, especially safety mechanisms such as understanding the basics of medication administration.
Although RaDonda has claimed she was “distracted” when she injected her patient Charlene Murphey with a fatal dose of a paralyzing agent, Vecuronium, prosecutors claim she made at least 10 mistakes on her way to the delivery of the drug.
RaDonda was working as a float nurse in the Neuro-ICU at the time, and she was training a new nurse. She was called to provide a sedative for Ms. Murphey, who had requested one prior to a PET scan. RaDonda checked in an electronic dispensing machine for Versed but did not find it, not realizing it was stored under the generic name of Midazolam. Instead, she overrode the dispensing machine software by entering “VE” and obtained Vecuronium.
She did not double-check the medication at the machine, or at the bedside, nor did she notice the warning label across the top of the vial of the drug that says “warning paralyzing agent” as she mixed the powder with a liquid before injecting it into the patient. It seems she missed many opportunities to stop and check herself, such as calling another provider to question why the medication needed so many steps to be completed before delivery. Nor did she stay and monitor the patient after injecting the medication, even though she was expecting the medication to be in a syringe and not an admixture. If she had, she might have noticed the patient turning cyanotic and being unable to breathe, before suffering a cardiopulmonary arrest in the scanner.
But do all these events warrant a felony arrest? According to an analysis by David Marx, JD in Medscape, they do. He discusses when we need to be concerned about the drift in nursing between a shortcut here and a workaround there, and the total collapse of patient safety systems. If RaDonda was taking as many liberties with the nursing process and an absolute drought of patient safety while training a new nurse, imagine what her practice might be like on a usual day sans trainee. Does she frequently administer medication that she has absolutely no idea what they might do once they enter a human body? OMG!
If so, she has no business caring for anyone ever, ever again, and a punitive process is probably what needs to take place as opposed to counseling.
To be fair, though, there were issues on both sides of this case, and Vanderbilt University Medical Center had “system and management deficiencies recognized by the Centers for Medicare and Medicaid Services (CMS)”, which placed the hospital at risk for losing funding until they filed a plan for corrective action. They did not have a system in place for requiring a second check when overrides occurred, nor did they require barcode scanning of medication given at the PET scanner. Vital sign checks were also not required for patients entering scanning labs. Many of these deficiencies allowed the death of Ms. Murphey to initially be reported as one of the natural causes, and not resulting from a medication error at all. The confusion and follow-up had to be heartbreaking for her family members, who have gone on record as saying they do not have harsh feelings for the nurse, but also, do not rule out litigation regarding the facility.
But, how do the rest of us feel?
Personally, I am appalled by a nurse who could ignore every opportunity to check or double-check a medication or Google the word Versed or do anything other than the actions she took. I’m not talking about negligence, I’m talking about blatant disregard, disrespect for anything she might have learned about patient safety and medication administration. Charlene Murphey, 75, was recovering from her subdural hematoma. She had a family who loved her and was waiting for her at home. And in Tennessee, the law says she was criminally robbed of her remaining days by a nurse who had forgotten how to perform her job.
In this case, I may have to agree with them. Charlene was brutalized. She asked for sedation prior to a PET scan because she was anxious. RaDonda injected her with a drug that left her alone on a radiology table, wide awake and paralyzed, unable to draw breath, until she lost consciousness and her heart stopped beating. I can’t imagine a worse fate.
This should never happen again.