As a nurse faces prison for a deadly error, her colleagues worry: Could I be next?

[Jilly_in_VA]

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's breathing and left her brain-dead before the error was discovered.

Vaught, 38, admitted her mistake at a Tennessee Board of Nursing hearing last year, saying she became "complacent" in her job and "distracted" 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.

"I know the reason this patient is no longer here is because of me," Vaught said, starting to cry. "There won't ever be a day that goes by that I don't think about what I did."

If Vaught's story had followed the path of most medical errors, it would have been over hours later, when the Tennessee Board of Nursing revoked her license and almost certainly ended her nursing career.

But Vaught's 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, the 75-year-old patient who died at Vanderbilt University Medical Center in late December 2017. If convicted of reckless homicide, Vaught faces up to 12 years in prison.

https://www.npr.org/sections/health-shots/2022/03/22/1087903348/as-a-nurse-faces-prison-for-a-deadly-error-her-colleagues-worry-could-i-be-next
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Prosecutors are wrong. It could happen to any of us, especially with the deadly understaffing in hospitals now.

[CrispyQ]

1. I'm surprised we have any nurses left at all, after some of the stories I've read. True heroes. -nt

[leftyladyfrommo]

9. Nurses and teachers. Why keep on working

at a job that is awful? You just can't expect employees to put up with such deplorable working conditions.

[mitch96]

2. It happened to my best friend but with NO consequences...

She was thrown from a horse and in the hospital for treatment of the trauma..
While visiting I noticed that the bag of liquid going into her arm had a different name on the bag. I turned off the liquid and called the nurse. She "flippantly" said "oops" got the right bag and went on her way. uff..
The hospital has a barcode system to prevent this from happening. Barcode the patients name, barcode the order, remove the drug from the electronic medication cabinet , Barcode the drug to the patients chart and administer the drug. "Almost" fool proof but we found the fool...
Turns out both bags were just normal saline but the repercussions of the "oops" could have been disastrous..
m

[ripcord]

3. The fact that she ignored mulitiple warning is being held against her

The case hinges on the nurse's use of an electronic medication cabinet, a computerized device that dispenses a range of drugs. 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, then searched for "VE" 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 "look directly" at a bottle cap that read "Warning: Paralyzing Agent," the DA's documents state.

[Jirel]

5. Yep. Definitely NOT just a normal error.

This is NOT “something that could happen to any” nurse. This is negligence after negligence after warnings after more negligence.

Nurses and doctors CAN say no to idiotic working conditions, by the way. Activism, even including slowdowns, sick-outs, strikes, etc., IS the way to go if conditions are so bad. If a nurse wants to say that this could happen to anyone because they’re so overworked, then it’s time to either do the scary part of the duty and stand up with others in the same position, or leave the field before they kill someone.

[Doodley]

7. Not easy to say no in the workplace. Expected consequences are being sidelined, persecuted, fired.

[Rustynaerduwell]

4. A reason why mistakes like this happen is that every drug has more than one name,

a "generic name" and several "brand" names. This is one ridiculous side effect of medicine being part of the free marketplace of capitalism. "Verced" is the brand name of the drug midazolam. Vecuronium is its own drug's generic name. Consider how stupid this system is. I've been a nurse for nearly twenty years and I still have to remind doctors that "Norco" is not the same drug as "Percocet", but it is the same drug as "Lorcet" or that "Lortab" is the same as "Norco", but is only available as a liquid syrup and is not available as a tablet, even though it has "tab" in its name. A drug should have one unique name, but pharma companies need to make money, so drugs are given brand names to better market them. Yes, this nurse was responsible for the death of this patient, but this accident, like many others like it, would not have happened if confusion over brand versus generic names was left out of the equation.

[Doodley]

8. Very good point.

[Volaris]

13. And then the computer TOLD HER to double, and then triple check,

That the thing she was trying to do, was actually what she wanted to do, and she damnwell didnt.

Being a nurse requires a brain capable of critical thinking, because you're doing Hard Science for Actual Money.

The pandemic has taught me, as someone who has worked in healthcare, that there are a lot of peeps who shouldnt be in that field, because their brains just dont work that way.

I've had nurses with advanced degrees tell me 'I dont want to get a covid vax because I dont trust the science.'

Then gtfo. If you worked at NASA, and told them you didnt 'trust' the math of how gravity worked, they wouldn't let you keep launching rockets. Because fuck you, that's why.

(On Edit)-- the computer was better at her job than she was. Consider that for a second.

[Doodley]

38. That may be so, but we are all fallible. Even the most alert and critical thinking of us can

makes mistakes, have off-days, be in a daze from lack of sleep or be affected by medication or health issues.

[WhiskeyGrinder]

6. Criminalizaiton helps no one in this situation.

[GoodRaisin]

14. This.

Some mistakes are terrible but they are not crimes. We have civil courts for this reason.

[jmowreader]

10. The first question that comes to mind...

Since this is a drug only used by the anesthesia service, why is it stored in a common use cabinet?

[Sgent]

37. Its also used

routinely in the ED and ICU (and she got this from the ICU pyxis). It is also used routinely when intubating so it may be available in crash carts or other locations.

[likesmountains 52]

11. In our NICU, 2 RNs must log in and verify removal of dangerous drugs.

Sometimes it seems arduous, but I can see how important it can be.

[Jilly_in_VA]

21. THIS

Right here. That's what I don't get. The hospital failed her and all the other nurses by not having THIS safeguard.

[MenloParque]

12. Don't most EHR systems have barcode medication administration??

I know EPIC and other EHR systems (Cerner, allscripts) has a barcode system in place to prevent these situations! If there was no scanning done when the policy is in place then absolutely negligent. Being Epic certified and train others in ambulatory these mistakes should not be occurring!

[Chakaconcarne]

17. Yep, the failsafe would have been a Med Order in the system that's mapped to a specific drug.

and the infrastructure in place to ensure closed loop....

Medication NDC is mapped to the drug in the system by pharmacy. Order is entered by physician, order is checked by pharmacist, Drug is stocked to med cabinet by pharmacy and drug barcode is scanned to ensure it's stocked in the correct location for that drug... nurse scans patient identification barcode, Med cabinet dispensing system presents available medications for that patient, Nurse scans patient ID barcode in eMAR, selects drug/administration and scans the drug at the eMAR (which checks that med against the patient Med order profile) ahead of administration.

[tishaLA]

16. She admits to being "complacent" in her job and "distracted"

and I'm supposed to believe prosecuting her for her complacency is wrong? So qualified immunity for nurses, too? I appreciate that nursing is a tough job, but it's probably a bad idea to become complacent when you're injecting people with powerful drugs.

[Chakaconcarne]

19. Her employer failed her and other nurses miserably by not setting up appropriate safeguards

In this day and age, they're just a no-brainer.

[ripcord]

30. They had appropriate safeguards

The problem is she ignored multiple warnings that the drug she had requested by overriding the system caused paralysis. No safeguards work when you jusr ignore the system warnings.

[Horse with no Name]

18. This is tragic

However, as a nurse, I seriously question the safeguards she bypassed.

[Jilly_in_VA]

20. Those who are not nurses

have no idea what the job is like. When you're understaffed and overworked and rushed, it's really easy to get distracted. As for her admitting to being "complacent", do you think maybe, just maybe, her lawyer told her to say that?

I do wonder at a couple of things, though. Like why did the hospital even HAVE Versed in the Pyxis? And why wasn't there a double-check system in place? In places I worked (and as a travel nurse, there were many, some of them critical care) certain drugs required two nurses to get them out of the Pyxis (trade name, used as generic by most of us). And Versed was never, EVER in any Pyxis, any place I ever worked, even in ICU. That had to be sent from the pharmacy and double-signed. It was occasionally used for bedside procedures, and it was a PITA to get...you'd usually have doctors tapping their feet and wondering why it took so effing long. (One nurse I worked with who had a smart mouth told the doctor with an innocent grin that he could go get it himself.) So this whole story is kind of weird to me.

[Hekate]

22. Good follow-up. I was struck by how many times the computer told her to check, recheck, recheck...

… and how many times she over-rode that.

I was on a jury in an appliance injury case against a landlord who improperly installed a stove. In his case he tossed the unopened packet of instructions on the kitchen counter and proceeded because “he knew how to do it.” During deliberations I had to point out to my fellow jurors that he didn’t just do one thing wrong — he did about 5 different things, and I enumerated them. They saw my point.

[Horse with no Name]

23. When I worked Neuro ICU

We had versed and vec in the Pyxis because we did intubate in our unit.
It would likely be unit specific though.

[TheProle]

27. Did you hold the same view

in the Kim Potter case?

[Hortensis]

34. Thanks for the discussion from those who've been there, guys.

[ecstatic]

43. Why did the patient need Versed in the first place?

Pointless overmedicating.

[struggle4progress]

24. She only made eleven consecutive errors, like anybody could

Mistake 1: did not search for generic name
Mistake 2: triggered cabinet override
Mistake 3: did not search for generic name again
Mistake 4: selected wrong drug
Mistake 5: ignored first cabinet warning/pop-up
Mistake 6: ignored second cabinet warning/pop-up
Mistake 7: ignored third cabinet warning/pop-up
Mistake 8: ignored fourth cabinet warning/pop-up
Mistake 9: ignored fifth cabinet warning/pop-up
Mistake 10: did not notice drug was powder instead of liquid
Mistake 11: ignored vial warning label

[Horse with no Name]

28. The last mistake being

Right drug
Right route
Right time
Right dose
Right patient

You should always look at the label before you draw it, while you draw it and after you draw it.


These are cornerstones of nursing. They weren’t followed.

[Hortensis]

35. Generally agree. Of course, people seldom get the maximum sentence.

Imo, the jurisdiction is meeting its responsibility to society, and the victim, in prosecuting this case.

Also disagree with the no-responsibility reaction of some here. While reliably represented on threads across a variety of issues, it's not characteristic of liberal or Democratic beliefs.

[ecstatic]

41. Agreed, but I also wonder--did the electronic cabinet give multiple warnings for every drug

or just drugs like the one she took out the cabinet that day? Sometimes a warning becomes ineffective if it's overused for everything. However, I think the nurse described it best--she was complacent, and therefore reckless with the lives of patients. I know we're all exhausted but when you get to that point, it's time to take a vacation. Don't endanger patients.

[Doodley]

39. Humans can make mistakes.

[struggle4progress]

42. That is certainly true.

[XanaDUer2]

25. Why was she overriding security checks?

I read overrides are common. Scary

[Sympthsical]

26. She literally bypassed safeguard after safeguard

Complacency is too soft a word for the details of how this happened. This was pure negligence.

She had to knowingly and willingly overlook multiple points of evaluation in order to make this mistake. It wasn't just, "Whoops, grabbed the wrong thing." She had to ignore everything the computer warned her about, the physical state of the medication, and the labels right before her eyes.

12 years in prison? I don't think so.

But this is one of the more egregious screw ups I've ever heard. And I don't think the employer had anything to do with it. It's weird people are so ready to exculpate her to varying degrees. Her behavior is pretty bad.

As someone currently studying to be a nurse, this story is going to stick in my mind. Right now, I'm just thinking, "How did she ignore everything she could possibly ignore?"

I'm sorry, but I'm not very understanding of this. There's "Oops, could've happened to anyone!" and the willful behavior and negligence involved here.

[ripcord]

32. Her career is over

I can see why they want to prosecute her but I honestly think a couple of years probation would be appropriate.

[Sympthsical]

45. Yeah, I don't want prison

But it feels like it's being downplayed. Like just being absent-minded.

It was pretty bad to ignore all the red flags in her face. That wasn't distracted. That was out of farks to give.

[Doodley]

40. You don't know what her state of mind or her health was like, what stress she was under in and out

of work, how much sleep she had had, or anything else about her.

[Demovictory9]

31. Big mistake

[Meowmee]

33. It was not a simple error

Which is why she is being charged etc. My father was murdered in a hospital while I tried desperately to save him. There were numerous events of gross negligence including harassment of myself. This type of thing is happening all over the country and with elderly people there is often no consequence. Bringing even a mps is almost impossible because the system is set up to protect medical professionals and hospitals etc. It happened to me as well, I was lucky to survive. My uncle saved a patient years ago when he was a med student after a colleague's gross error, when he tried to report it his supervisor told him not to because it would ruin his career.

[Bonx]

36. Kim Potter got two years. I'm guessing she will get around the same.

[Jilly_in_VA]

44. Unless you hold nurses

to a higher standard than cops, she shouldn't get any more than that.

[bluecollar2]

47. In the airline business

Safety sensitive procedures rely on the "two sets of eyes" process.

In this case a change in procedures may be warranted by disallowing the override action to be authorized by the same person.

I believe it's the same way with parachutes. Main and reserve chutes are packed by two different riggers