Former Vanderbilt University Medical Center (VUMC) nurse RaDonda Vaught was found guilty on March 25 of criminally negligent homicide and gross neglect of an impaired adult in the 2017 death of 75-year-old Gallatin resident Charlene Murphey. The jury found Vaught not guilty of reckless homicide.
On Dec. 26, 2017, Vaught mistakenly injected Murphey with the paralyzing drug vecuronium instead of the anti-anxiety sedative Versed. Murphey died the next day. VUMC fired Vaught on Jan. 3, 2018, and the District Attorney’s office arrested Vaught for her alleged role in Murphey’s death on Feb. 4, 2019.
“Multiple health care professionals were on the jury. The jury found a series of decisions were made by Vaught to ignore her nursing training, and instead, failed to adhere to safety protocols that proved to be fatal,” a March 26 statement from the Davidson County District Attorney’s Office to WKRN reads. “The jury felt this level of care was so far below the proper standard of a reasonable and prudent nurse that the verdict was justified.”
Vaught’s sentencing hearing is scheduled for May 13, 2022. She faces three to six years in prison for gross neglect of an impaired adult and one to two years for criminally negligent homicide. Vaught told CBS News on March 29 that she has not yet considered whether she will appeal her sentence.
The case received nationwide attention due to questions over whether mistakes by medical professionals will be criminalized in the future. Medical mistakes are usually litigated in civil court or result in the revocation of a medical license. Vaught lost her nursing license in September 2019, after the Tennessee Board of Nursing reversed their initial decision to not pursue disciplinary action against Vaught and held a medical discipline hearing against her.
“I was very dismayed about the verdict finding her [Vaught] guilty. The nurse was guilty of making a horrendous error—she admitted it. But there were system errors involved as well,” Maureen Shawn Kennedy, editor-in-chief emerita of the American Journal of Nursing (AJN), said in an interview with The Hustler. “This was a nurse who, by all accounts, was there trying to do what she should have been doing and made an egregious error because she didn’t follow a procedure. Does that deserve time in jail? I don’t think so.”
VUMC declined to comment on the criminal proceedings. Vaught’s attorney Peter Strianse has not responded to The Hustler’s requests for comment.
“Ms. Murphey’s family is at the forefront of my thoughts every day,” Vaught said in a March 25 interview with AP News. “You don’t do something that impacts a family like this, that impacts a life, and not carry that burden with you.”
Timeline of events
As part of treatment at VUMC for a brain bleed, Murphey was taken to the radiology department to receive a PET scan on Dec. 26, 2017. Her condition had been reportedly improving before the scan, and she was prescribed Versed due to her claustrophobia. Vaught instead injected Murphey with vecuronium, and Murphey became brain-dead within 30 minutes of receiving the drug.
According to a Tennessee Bureau of Investigation (TBI) report, VUMC utilizes an electronic medication cabinet to dispense drugs. The report and Vaught state that she searched “VE” to try to withdraw Versed from the cabinet, unaware that the drug was listed under its generic name, midazolam. Vaught admitted in the report to being “distracted” while searching for the medication because she was training an orientee nurse.
When the search was unsuccessful, Vaught triggered an override to unlock a larger range of medications and searched “VE” again. Per the report, Vaught ignored or overrode five warnings stating that she was withdrawing a paralyzing medication. The report also lists five “red flags” that Vaught also failed to recognize, including that vecuronium is a powder while Versed is a liquid, and that the cap for the vecuronium bottle reads “Warning: Paralyzing Agent.”
After realizing that she had administered the wrong medication due to Murphey undergoing cardiac arrest, Vaught stated that she informed hospital staff immediately.
VUMC neurologists initially reported Murphey’s death to the Davidson County Medical Examiner on Dec. 27, 2017, with no mention of the medication error. VUMC instead attributed Murphy’s death to “natural causes” and complications related to her “intracerebral hemorrhage,” stating there was “no foul play suspected.”
The TBI report includes a letter from Marcee Lupica, associate nursing officer at the VUMC Neuroscience Patient Care Center, and Misty Ashby, VUMC neuro ICU manager, to Vaught from January 2018. The letter stated that the hospital had decided to fire her after an internal investigation and interview. According to The Tennessean, Vanderbilt also negotiated an out-of-court settlement with Murphey’s family, prohibiting them from speaking publicly about the death. As of print, Vaught’s LinkedIn states that she began working as a “throughput coordinator” at TriStar Centennial Medical Center in May 2018.
The Centers for Medicare and Medicaid Services (CMS) began an investigation into VUMC in November 2018 in response to an anonymous tip. The CMS published a public report about the error on Nov. 19, 2018, which included interviews with Vaught, though she was not named, and other VUMC personnel.
VUMC did not report the medication error to state or federal governmental officials, despite it being mandated by the Health Data Reporting Act of 2002, as outlined by the CMS report.
The report threatened to suspend Vanderbilt’s Medicare reimbursements, which constituted about 22% of their funding at the time. VUMC submitted a corrective action plan with now-implemented procedures, such as shrink-wrapping paralyzing medications and adding additional warnings in the electronic system, which CMS accepted.
The Davidson County District Attorney’s Office also began an investigation into the matter on Dec. 15, 2018, resulting in Vaught’s 2019 indictment. Vaught pled not guilty to all charges, which included reckless homicide and gross neglect of an impaired adult. Strianse stated that Vaught made a mistake that should not be categorized as a crime because Vaught had no intent to cause harm. Vaught waived her right to testify during the trial.
“I know the reason this patient is no longer here is because of me,” Vaught testified during the 2018 Tennessee Board of Nursing proceeding. “There won’t ever be a day that goes by that I don’t think about what I did.”
Strianse argued that “systemic problems,” such as with electronic medication cabinets at VUMC, were more to blame for Murphey’s death. He claimed that Vaught was a “scapegoat” in the situation.
“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,” Strainse said during his oral opening statement. “Vanderbilt University Medical Center? They found a seat.”
VUMC Pharmacy Medication Safety Officer Terry Bosen countered in the proceedings that any previous technical problems with medication cabinets at VUMC were resolved before the incident occurred.
“This wasn’t an accident or mistake as it’s been claimed,” Assistant District Attorney Chad Jackson said during the trial. “There were multiple chances for RaDonda Vaught to just pay attention.”
Responses to the case
While waiting for the verdict to be announced, Vaught stated that she does not regret being honest about her error to government officials and VUMC personnel.
“I’m not saying I’m not responsible for my actions, not at all. I’ve been very clear with everyone I’ve spoken with—the TN Department of Health, multiple investigators, Vanderbilt, TBI, everyone. I have not shied away from my responsibility, but health care is a system,” Vaught said in a March 25 interview with WTVF. “I don’t go to work in a vacuum. I work in a health care system.”
Nurses across the country have publicly disagreed with the verdict, stating that they believe this case will set a precedent for criminalizing medical errors, will disincentivize medical practitioners from honestly reporting their mistakes and will deter people from joining the nursing profession. As of print, a petition calling for clemency for Vaught has received 160,503 signatures.
“The criminalization of medical errors is unnerving, and this verdict sets into motion a dangerous precedent. There are more effective and just mechanisms to examine errors, establish system improvements and take corrective action,” a March 25 statement from the American Nurses Association (ANA) reads. “The non-intentional acts of individual nurses like RaDonda Vaught should not be criminalized to ensure patient safety.”
The Davidson County District Attorney’s office countered this argument, stating that Vaught’s case is not precedent-setting.
“I’m not an attorney, so I can’t say for sure what makes a precedent but it seems to me once you have one case, it’s easier to have another,” Kennedy said. “In terms of what this means professionally, I think it’s a really bad message to people who are trying to do the right thing. People are less likely to come forward and admit they’ve made a mistake because they worry about getting blamed or punished.”