NASHVILLE, Tenn. 鈥� Four years ago, inside the most prestigious hospital in Tennessee, nurse RaDonda Vaught withdrew a vial from an electronic medication cabinet, administered the drug to a patient, and somehow overlooked signs of a terrible and deadly mistake.
The patient was supposed to get Versed, a sedative intended to calm her before being scanned in a large, MRI-like machine. But Vaught accidentally grabbed vecuronium, a powerful paralyzer, which stopped the patient鈥檚 breathing and left her brain-dead before the error was discovered.
Vaught, 38, admitted her mistake at a last year, saying she became 鈥渃omplacent鈥� in her job and 鈥渄istracted鈥� by a trainee while operating the computerized medication cabinet. She did not shirk responsibility for the error, but she said the blame was not hers alone.
鈥淚 know the reason this patient is no longer here is because of me,鈥� Vaught said, starting to cry. 鈥淭here won鈥檛 ever be a day that goes by that I don鈥檛 think about what I did.鈥�
If Vaught鈥檚 story followed the path of most medical errors, it would have been over hours later, when the Board of Nursing revoked her RN license and almost certainly ended her nursing career. But Vaught鈥檚 case is different: This week she goes on trial in Nashville on criminal charges of reckless homicide and felony abuse of an impaired adult for the killing of Charlene Murphey, a 75-year-old patient who died at Vanderbilt University Medical Center on Dec. 27, 2017.
Prosecutors do not allege in their court filings that Vaught intended to hurt Murphey or was impaired by any substance when she made the mistake, so her prosecution is a rare example of a health care worker facing years in prison for a medical error. Fatal errors are generally handled by licensing boards and civil courts. And experts say prosecutions like Vaught鈥檚 loom large for a profession terrified of the criminalization of such mistakes 鈥� especially because her case hinges on an automated system for dispensing drugs that many nurses use every day.
The Nashville district attorney鈥檚 office declined to discuss Vaught鈥檚 trial. Vaught鈥檚 lawyer, Peter Strianse, did not respond to requests for comment. Vanderbilt University Medical Center has repeatedly declined to comment on Vaught鈥檚 trial or its procedures.
Vaught鈥檚 trial will be followed by nurses nationwide, many of whom worry a conviction may set a precedent even as the coronavirus pandemic leaves countless nurses exhausted, demoralized, and likely more prone to error.
Janie Harvey Garner, a St. Louis registered nurse and founder of Show Me Your Stethoscope, a nursing group with more than 600,000 members on Facebook, said the group has closely watched Vaught鈥檚 case for years out of concern for her fate 鈥� and their own.
Garner said most nurses know all too well the pressures that contribute to such an error: long hours, crowded hospitals, imperfect protocols, and the inevitable creep of complacency in a job with daily life-or-death stakes.
Garner said she once switched powerful medications just as Vaught did and caught her mistake only in a last-minute triple-check.
鈥淚n response to a story like this one, there are two kinds of nurses,鈥� Garner said. 鈥淵ou have the nurses who assume they would never make a mistake like that, and usually it鈥檚 because they don鈥檛 realize they could. And the second kind are the ones who know this could happen, any day, no matter how careful they are. This could be me. I could be RaDonda.鈥�
As the trial begins, the Nashville DA鈥檚 prosecutors will argue that Vaught鈥檚 error was anything but a common mistake any nurse could make. Prosecutors will say she ignored a cascade of warnings that led to the deadly error.
The case hinges on the nurse鈥檚 use of an electronic medication cabinet, a computerized device that dispenses a range of drugs. According to , Vaught initially tried to withdraw Versed from a cabinet by typing 鈥淰E鈥� 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 鈥渙verride鈥� that unlocked a much larger swath of medications, then searched for 鈥淰E鈥� again. This time, the cabinet offered vecuronium.
Vaught then overlooked or bypassed at least five warnings or pop-ups saying she was withdrawing a paralyzing medication, documents state. She also did not recognize that Versed is a liquid but vecuronium is a powder that must be mixed into liquid, documents state.
Finally, just before injecting the vecuronium, Vaught stuck a syringe into the vial, which would have required her to 鈥渓ook directly鈥� at a bottle cap that read 鈥淲arning: Paralyzing Agent,鈥� the DA鈥檚 documents state.
The DA鈥檚 office points to this override as central to Vaught鈥檚 reckless homicide charge. Vaught acknowledges she performed an override on the cabinet. But she and others say overrides are a normal operating procedure used daily at hospitals.
While testifying before the nursing board last year, foreshadowing her defense in the upcoming trial, Vaught said at the time of Murphey鈥檚 death that Vanderbilt was instructing nurses to use overrides to overcome cabinet delays and constant technical problems caused by an ongoing overhaul of the hospital鈥檚 electronic health records system.
Murphey鈥檚 care alone required at least 20 cabinet overrides in just three days, Vaught said.
鈥淥verriding was something we did as part of our practice every day,鈥� Vaught said. 鈥淵ou couldn鈥檛 get a bag of fluids for a patient without using an override function.鈥�
Overrides are common outside of Vanderbilt too, according to experts following Vaught鈥檚 case.
Michael Cohen, president emeritus of the Institute for Safe Medication Practices, and Lorie Brown, past president of the American Association of Nurse Attorneys, each said it is common for nurses to use an override to obtain medication in a hospital.
Cohen and Brown stressed that even with an override it should not have been so easy to access vecuronium.
鈥淭his is a medication that you should never, ever, be able to override to,鈥� Brown said. 鈥淚t鈥檚 probably the most dangerous medication out there.鈥�
Cohen said that in response to Vaught鈥檚 case, manufacturers of medication cabinets modified the devices鈥� software to require up to five letters to be typed when searching for drugs during an override, but not all hospitals have implemented this safeguard. Two years after Vaught鈥檚 error, Cohen鈥檚 organization documented a 鈥渟trikingly similar鈥� incident in which another nurse swapped Versed with another drug, verapamil, while using an override and searching with just the first few letters. That incident did not result in a patient鈥檚 death or criminal prosecution, Cohen said.
Maureen Shawn Kennedy, the editor-in-chief emerita of the American Journal of Nursing, wrote in 2019 that Vaught鈥檚 case was
In the pandemic, she said, this is truer than ever.
鈥淲e know that the more patients a nurse has, the more room there is for errors,鈥� Kennedy said. 鈥淲e know that when nurses work longer shifts, there is more room for errors. So I think nurses get very concerned because they know this could be them.鈥�