A former nurse at Vanderbilt University Medical Center is scheduled for sentencing in May for negligent homicide and gross neglect of an impaired adult, in a case that the American Nurses Association (ANA) and other nursing profession advocates say should have been handled by a nurse licensing board or in civil court, rather than criminal prosecution.1

"ANA believes that the criminalization of medical errors could have a chilling effect on reporting and process improvement," said a statement issued by the ANA on Wednesday, March 23, 2022, the first day of the trial of RaDonda Vaught, a former nurse at Vanderbilt University Medical Center in Nashville.

"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," the ANA statement continued.1

Although this case occurred in 2017, before the coronavirus disease (COVID-19) pandemic began in early 2020, the ANA also noted stress that nurses have faced during the pandemic.

"COVID-19 has already exhausted and overwhelmed the nursing workforce to a breaking point," the ANA statement said. "Nurses are watching this case and are rightfully concerned that it will set a dangerous precedent. ANA cautions against accidental medical errors being tried in a court of law."

Vaught was found guilty March 25 after a 3-day trial in Nashville, Tennessee. When she goes before a judge for sentencing, scheduled for May 13, she will face 3 to 6 years in prison for neglect and 1 to 2 years in prison for negligent homicide, and as a defendant with no prior convictions, she most likely will serve those sentences concurrently, according to an article by Kaiser Health News and National Public Radio.2

Vaught has admitted her role in the error, and has lost her license from the state's nursing board, but she has said the error was possible because of flawed procedures and technical problems at Vanderbilt.3

Sequence of Events

According to the Kaiser-NPR coverage of the trial, here is what happened:

A patient, Charlene Murphey, age 75, had been admitted to Vanderbilt with a brain injury. As she improved and was preparing for discharge, she was scheduled for a magnetic resonance imaging (MRI) scan. The patient was prescribed Versed as a sedative for the procedure.

According to the investigation, Vaught retrieved the wrong medication from a computerized medication cabinet. Instead of Versed, she removed vecuronium, a powerful paralytic agent. The investigation reported that Vaught overlooked several clues that she withdrew the wrong drug. For example, the Versed would have been in liquid form, and the vecuronium is a powder. Vaught injected vecuronium into the patient and "left her to be scanned," according to the NPR-Kaiser article. By the time the mistake was detected, the patient was brain-dead.

The error occurred partly because Vaught used an override option available from the computerized medication cabinet, which compounded an initial mistake she made.

"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. 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. This time, the cabinet offered vecuronium" according to an article from the first day of the trial.3

Prosecutor Calls Override Reckless

In the trial, this override is what prosecutors described as a "reckless" act that is the basis for the reckless homicide charge. Vaught was acquitted of reckless homicide, which is a more serious charge than negligent homicide.

The NPR-Kaiser article reported that experts say cabinet overrides are a daily event at many hospitals.

"Vaught insisted in her testimony before the nursing board last year that overrides were common at Vanderbilt and that a 2017 upgrade to the hospital's electronic health records system was causing rampant delays at medication cabinets. Vaught said Vanderbilt instructed nurses to use overrides to circumvent delays and get medicine as needed," the article reported.

Prosecution and Defense Arguments

The prosecutor, Chad Jackson, assistant district attorney, compared Vaught to a drunk driver killing a bystander, but said what she did was worse, like "driving with [her] eyes closed."

Vaught's attorney, Peter Strianse, said she had made a mistake that did not constitute a crime. He said there were systemic issues with Vanderbilt's medication cabinets. The medical center's medication safety officer testified that those technical problems "were resolved weeks before" Vaught administered the wrong medication to Murphey.

However, there are some unanswered questions about Vanderbilt Medical Center that came up during the trial.

According to an NPR story from the first day of the trial, Vanderbilt had taken several actions after the patient died that resulted in the medication error not being disclosed to safety and health care regulators.3

The NPR-Kaiser coverage from that day reported that "The hospital told the local medical examiner's office that Murphey died of 'natural' causes, with no mention of vecuronium, according to Murphey's death certificate and Davidson County's chief medical examiner, Dr. Feng Li."

The medical center fired Vaught and negotiated an out-of-court settlement with the patient's family, in which the parties are not to discuss the death publicly.

According to the NPR-Kaiser article, the medication error was not revealed until months after the patient died. An anonymous tip alerted the Centers for Medicare & Medicaid Services and the Tennessee Department of Health. The health department also alerted the Tennessee Bureau of Investigation (TBI).

A TBI agent, Ramona Smith, testified that her investigation focused only on Vaught's drug error, but that she believed Vanderbilt did not accurately document the patient's cause of death on the death certificate. However, Smith said she did not investigate this as a potential crime.3

During Vaught's trial, a Vanderbilt neurologist testified that it was "in the realm of possibility" that the death was a result of the brain injury rather than the vecuronium.

ANA Concern About Undermining Just Culture

The ANA statement said that criminalizing and prosecuting medical errors will be harmful to patient safety.

"Health care is highly complex and ever-changing, resulting in a high risk and error-prone system," the statement said. "Organizational processes and structures must support a 'just culture,' which recognizes that health care professionals can make mistakes and systems may fail. All nurses and other health care professionals must be treated fairly when errors occur. ANA supports a full and confidential peer review process in which errors can be examined and system improvements and corrective action plans can be established. Swift and appropriate action should and must always be taken as the situation warrants."

"Transparent, just, and timely reporting mechanisms of medical errors without the fear of criminalization preserve safe patient care environments. ANA maintains that this tragic incident must serve as reminder that vigilance and open collaboration among regulators, administrators, and health care teams is critical at the patient and system level to continue to provide high-quality care," the statement said.

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